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NURSES' EXPERIENCES OF
FULL SCOPE LPN PRACTICE
IN ACUTE CARE
by
ELIZABETH SARAH MCTAGGART
B.A., University of British Columbia, 1996 B.S.N. (Hons), University of British Columbia, 1999
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING
In
THE FACULTY OF GRADUATE STUDIES
THE UNIVERSITY OF BRITISH COLUMBIA
April 2007
© Elizabeth Sarah McTaggart, 2007
Abstract
The practice of licensed practical nurses (LPNs) in acute care in British
Columbia (BC) is undergoing a shift to incorporate the enhanced range of entry-
level competencies introduced by the College of LPNs of British Columbia in
2000. The full range of new LPN competencies, which now constitute full scope,
became a requirement for practical nurse licensure in BC in 2007 and are
challenging LPNs and Registered Nurses (RNs) alike to reexamine and redefine
the LPN role and LPN/RN relations in acute care. Research exploring the
experiences of RNs and LPNs, in their own words, with full scope LPN practice in
acute care staff mixes has not previously been conducted in BC.
This qualitative descriptive study explored the perceptions of 5 RNs and 4
LPNs working in RN/LPN skill mixes, in various Lower Mainland acute care
settings where the LPNs work to full scope. Conventional qualitative content
analysis was used to analyze the data from one in-depth interview and 8 short-
answer surveys. Analysis of one in-depth interview with an LPN yielded 3
categories: professionalism, receptivity, and appropriateness. Analysis of the 8
survey responses from RNs and LPNs yielded 3 categories as well, namely:
defining the role, determining the impact and determining the fit of the role.
Findings in this study indicate that overall, both RNs and LPNs report that clear
communication, LPN role clarity, experience working together over time, and a
supportive work environment contribute to positive experiences of the RN/LPN
skill mix.
Feelings of burden, inconsistent teamwork, lack of respect, concerns about
patient acuity levels, and varied perceptions of the ability of LPNs and RNs to
assume responsibility for patient care present areas of challenge in the
workplace.
iv
T A B L E OF CONTENTS
Abstract "
Acknowledgment vi
CHAPTER I Introduction 1
1.1 Background to the Problem 1 1.2 Problem Statement 5 1.3 Purpose of the Study 5 1.4 Research Question 6 1.5 Definition of Terms 6 1.6 Assumptions 7 1.7 Summary 8
CHAPTER II Literature Review 10
2.1 The Changing LPN Role in BC 10 Changes in LPN Competencies 11
2.2 Full Scope Practice 14 Utilization and Integration of Full Scope LPNs in BC 15 LPNs in Acute Care 15
2.3 RN/LPN Workshops 16 2.4 Summary 18
CHAPTER III Methodology 19
3.1 Purpose 20 3.2 Qualitative Description 20 3.3 Recruitment 23 3.4 Procedures 26
Data Collection 26 Data Analysis 28
Content Analysis 29 3.5 Criteria for Affirming Rigor 30
Auditability 30 Creditability 31 My Audit Trail Discussed 32
3.6 Shift to Surveys 34
CHAPTER IV Data and Analysis 35
4.1 The Nature of My Question 35 4.2 What Happened: A Chronology 35
Initial Recruitment Efforts 36
V
Participants 37 Three Expressions of Interest: One Interview 38
4.5 Analysis of Interview with Participant 001 41 Professionalism 43
Professionalism Challenged 44 Professionalism Asserted 46
Receptivity 49 Receptivity: A Lack Thereof 50
Appropriateness 57 4.6 Transition to Surveys 58 4.7 Analysis of the Surveys 59
Defining the Role 61 Determining the Impact of the Role 66
Burden 66 Teamwork 69 Personal Impact 72
Determining the Fit of the Role 75 4.8 The Interview and the Surveys 79
CHAPTER V Discussion 82
5.1 Research Conclusions 83 5.2 Related Work 87 5.3 Implications 89
Implications for Nursing Practice 89 Implications for Nursing Education 92 Implications for Policy 93 Implications for Nursing Research 95
5.4 Summary 96
Reference List 99
APPENDIX I Ethics Approval Form 103
APPENDIX II Recruitment Notice 104
APPENDIX III Letter of Consent 105
APPENDIX IV Initial Interview Guide.. 108
APPENDIX V Demographic Data 109
APPENDIX VI Survey 110
vi
Acknowledgements
I would especially like to thank the nurses who participated in this study. Thank you for sharing your experiences and insights.
This thesis is the culmination of years of work and marks the conclusion of a long academic journey. I am grateful to my committee members, Dr. Angela Henderson (chair), Dr. Sonia Acorn, and Dr. Carol Jillings for their support, guidance and for making sure I always saw the light at the end of the tunnel.
I would also like to thank my nursing colleagues, in particular Kathy Fukuyama, for their support. To my friends, in particular Raul, Steve, Jay, and Kristi thank you for checking in on me regularly and keeping me in the loop. I found my dancing shoes and am so glad to be rejoining you now.
Finally I would like to thank my dear family. Thank you for your unyielding support, understanding and love. Mom and dad, thank you for believing in me and encouraging me, especially on those days when my confidence faltered. To my mom, thank you for showing me the joy to be had in writing.
C H A P T E R I
Introduction
In this chapter I will present background information that not only stimulated
my interest in pursuing this research but also provided me with a basis of
understanding as I formed my research question. I will then provide a statement
of the problem and the research question which I developed in response to it.
Next, I will clarify two key terms that are utilized throughout this study, namely full
scope and competencies. Finally I will end with a brief description of my
assumptions as a researcher approaching this study. In the following chapter I
will explore the relevant literature in more depth.
Background to the Problem
Health care service restructuring, a shortage of registered RNs in British
Columbia (BC) and an ongoing interest in cost containment strategies in health
care have resulted in an increasing number of LPNs being
integrated/reintegrated into staff mixes in various health care delivery settings
(e.g. acute care hospital and long term care facilities) (Greenlaw, 2003; Lantz,
2004; McPherson, 2004). At the same time, the scope of practice for LPNs has
expanded with the introduction of an enhanced range of competencies
introduced by the College of Licensed Practical Nurses of British Columbia
(CLPNBC) in 2000 which has increased opportunities for LPN utilization in
various practice settings (CLPNBC, 2000; Greenlaw). According to Catherine
Overton, former Deputy Registrar for the CLPNBC, in 2004 a full 2/3 of LPN
registrants worked in acute care settings (personal communication, August 23,
2004). However, the move towards widespread utilization of LPNs to full scope in
this setting is limited and inconsistent, despite the introduction of the expanded
scope and new range of competencies in 2000.
The term 'full scope' of practice refers to far more than skills, and is not limited
in application to the nursing practice of LPNs. In their discussion paper
examining proposed implementation guidelines for deploying full scope LPNs
(FSLPNs in this study) in Alberta's health authority employment settings, the
Health Authorities Health Professions Act Regulations Review Committee
(HAHPRRC), defined full scope as "deploying health professionals to the full
range of their roles, responsibilities and functions they are educated, competent
and authorized to perform" (HAHPRRC, 2002, p.7). However, according to
Donna Nicholson, RN, recent LPN facilitator for Vancouver Coastal Health, the
term full scope is generally considered "an employer term" used by employers to
differentiate between "traditional" LPNs and those prepared to function within
their enhanced scope of practice (personal communication, January 12, 2005).
Currently, full scope practice for LPNs in BC includes expansion into 6 select
competency areas outlined in 2000 by the CLPNBC: a) comprehensive
assessment; b) medication administration including administration of range
doses (e.g. including administration of range doses and taking and transcribing
doctor's orders); c) wound management; d) airway management; e) elimination
management; and f) infusion management (e.g. non-medicated infusions)
(CLPNBC, 2000; CLPNBC, 2004; Greenlaw, 2003). As of 2006, LPNs in British
Columbia were required to demonstrate knowledge and practice capabilities that
3
cover the enhanced range of competencies constituting 'full scope' practice in
order to register with the College of LPNs of BC (CLPNBC). However, the
deadline for meeting the enhanced competencies within medication
administration (e.g. pharmacology) was moved to January, 2007 (CLPNBC,
2004).
The introduction and utilization of full scope LPNs in BC has been
inconsistent. For example, an LPN on one acute care unit may practice to full
scope while another on a similar unit at another facility may be limited (e.g.
unable to administer medications). On some units, LPNs might not be part of the
skill mix at all and the unit might be staffed solely by RNs or RNs and care aides.
On other units particularly in long term care, RN positions have been eliminated
and replaced with LPNs (McPherson, 2004). Changed in staff mixes involving
LPNs has, as a result, "been met with uncertainty, fear and in some instances
hostility and resentment" from RNs (McPherson, p.3). Several barriers to LPN
utilization to full scope have been identified. These barriers include: a) unclear
definitions of acuity ; b) misperceptions of LPN competencies; c) role confusion;
d) issues of territoriality; e) lack of support and assistance for LPNs; and f) lack of
resources for LPNs (e.g. educational funding) (Greenlaw, 2003; HAHPARRC,
2002). Despite potential impediments to the integration of FSLPNs, the trend is to
deploy increasing numbers of these nurses into the workforce, not only in BC but
across Canada. In their final report, the Canadian Nursing Advisory Committee
noted that employment practices that limits nurses from practicing to the fullest
of their capabilities, whether RN, LPN, or registered psychiatric nurse (RPN)
4
needs to cease, and that nurses should be supported in working to their fullest
professional capabilities in all settings (CNAC, 2002). In addition, the College of
Registered Nurses of British Columbia (CRNBC) position statement on nursing
staff mix and appropriate care acknowledges the current trend towards re-
engineering of nursing care delivery teams, and affirms the need for RNs to be
utilized to their maximal capabilities (CRNBC, 2007).
Utilization of full scope LPNs in the acute care setting poses some unique
challenges. Rising patient acuity, lower staffing levels, lack of sufficient support
and education for nurses and inconsistent utilization of LPNs that is not always
clearly defined has impacted both RNs and LPNs and left them with questions
"about patient care and safety of their practice" (McPherson, 2004, p.3).
According to the CRNBC (2005), in situations when the breadth of patient health
care needs increases (e.g. in acuity, complexity or variability), RNs and LPNs
need to collaborate more closely, and the RN needs to be more involved in the
provision of care. However, the defining criteria for increased breadth of patient
care needs are not clearly outlined.
In a joint effort between the CLPNBC and the CRNBC (formerly RNABC),
workshops were developed to address concerns and facilitate collaboration
among RNs and full scope LPNs in BC. Two former nursing practice consultants
(both active in practice at the inception of this inquiry and have since moved on
to other positions), Pamela Ottem and Janice Joyce, employed by the RNABC
and College of Licensed Practical Nurses of BC (CLPNBC) respectively have
been active in supporting the integration of full scope LPN practice in BC.
5
Problem Statement
In this time of role reorganization and clarification, the LPN Current Utilization
Advisory Committee recommended that reports be compiled that explored the
experiences of nursing teams (Greenlaw, 2003). Rob Calnan (2003), former
Canadian Nurses' Association (CNA) president and a LPN, has commented that
current restructuring of nursing care delivery teams poses a challenge to
traditional roles and role boundaries in nursing. Due to a number of factors
occurring in acute care contexts (e.g. increased patient acuity, less predictable
patient outcomes, and variation among employer utilization of LPNs), LPNs
working in these settings have not generally practiced at full scope.
Purpose of the Study
While full scope LPN utilization in acute care areas in BC is inconsistent at
present, the trend appears to be towards increased integration of full scope LPNs
into acute care nursing skill mixes (Greenlaw, 2003). In this study I explored the
experiences of RNs and LPNs practicing in acute care settings where LPNs are
practicing to full scope. Research participants included RNs and LPNs from
different acute care units in the Lower Mainland.
The purpose of this qualitative description study was to gain an
understanding of the perspectives of RNs and LPNs who are practicing alongside
or as full scope LPNs in the acute care setting. This research is a step towards
understanding the perspectives and experiences of both RNs and LPNs
regarding this issue of full scope LPNs in acute care settings. The current trend
6
toward increased implementation of full scope LPNs in acute care practice
settings coupled with the lack of information regarding how nurses perceive
these shifts in staff mix and nursing practice support, in my opinion, the need for
this descriptive study. A study that considers the perspectives of RNs and LPNs
in an acute care setting when faced with a change in the staff mix (e.g. addition
of full scope LPNs) will contribute to a better understanding of the situation and
add to the nursing practice/health care literature. This thesis offers an informed
contribution based on a review of information gathered from nurses (e.g. LPNs
and RNs) in the Greater Vancouver area.
Research Question
Based on my understanding of the issue as I have presented it and the fact
that there is little available information on the perspectives of nurses pertaining to
full scope LPN practice in acute care, my research question was, "What is the
experience of registered nurses and licensed practical nurses working with or as
full scope LPNs in the acute care setting?".
Definition of Terms
Full Scope
The term 'full scope' of practice refers to far more than skills, and is not limited
in application to the nursing practice of LPNs. In this study, I adopted the
definition of full scope practice as set out in a broad sense for all health care
providers by Alberta's Health Authorities Health Professions Act Regulations
Review Committee. Therefore, full scope refers to LPN practice that utilizes "the
full range of their roles, responsibilities and functions they are educated,
competent and authorized to perform" (HAHPRRC, 2002, p.7).
Competencies
For the purposes of this study, I have adopted the definition of competencies
outlined in the joint document on practice expectations of RNs and LPNs
produced by the CRNBC and CLPNBC, published by the CRNBC in 2005. LPN
competencies are, therefore, "statements about the knowledge, skills, attitude,
and judgment required" of the individual LPN in order to "perform safely and
ethically" within an individual's nursing practice or in a designated role or setting"
(CRNBC, p.4).
Assumptions
The lens through which a qualitative researcher views their research (e.g.
informed by personal agendas or biases) has the potential to influence and even
invalidate the research process (Morse & Field, 1995). Therefore, it is important
for researchers to develop, "a critical awareness of one's self and one's motives
for maximal performance in the research arena" (p.15). In my nursing
experience in several acute care environments (e.g. thoracic surgery and
neonatal intensive care), direct patient care was provided exclusively by RNs.
My more recent work as an LPN educator in both classroom and acute care
clinical settings has heightened my awareness of differences and similarities in
educational backgrounds and scopes of practice of RNs and LPNs in BC,
particularly in acute care areas (e.g. acute medical and surgical units). As a
result of my personal experiences, I entered this research process with certain
assumptions and beliefs regarding full scope LPN practice in acute care. The
central assumptions I hold are:
1. The implementation of full scope LPN practice in acute care is meeting
with skepticism and resistance from some RNs.
2. Some LPNs view the only notable differences between themselves and
RNs in the acute care setting as: a) only RNs are able to administer IV
medications and b) LPNs are paid less then RNs.
3. RN/LPN teams in acute care can be effective and deliver quality
patient care.
Summary
In this chapter I have outlined my area of research interest, identified the
purpose of the study and my research question, defined two important terms and
clarified my own assumptions as a researcher. In the next chapter I will explore
the relevant literature, with particular focus on the evolving role of the L P N in B C
and full scope LPN practice and utilization in the acute care practice setting. In
chapter 3,1 outline my methodology and the details of my planned approach to
data collection and analysis for this study. I also consider criteria for rigor. In
chapter 4, I present a chronology of how my study unfolded and the analysis of
data collected. Chapter 5 begins with a presentation of my research conclusions
with additional, relevant literature touched upon.
9
Following a discussion of the rigor and strengths and limitations of the study I
conclude with consideration of nursing implications and a final summary.
10
C H A P T E R II
L ITERATURE REVIEW
LPNs have been part of the Canadian nursing landscape since their
introduction around the time of the First World War, with their original nursing
assistant role evolving over the last twenty years into a more autonomous role
(Villeneuve & McDonald, 2006). This chapter sets out to review relevant literature
pertaining to the evolving role of LPNs in British Columbia. The literature
surveyed here includes such topics as: a) the changing LPN role in BC; b)
changes in LPN competencies; c) full scope practice; d) utilization and integration
of full scope LPNs in BC; e) LPNs in acute care in BC; and f) RN/LPN
Workshops. By no means is this literature review exhaustive. However, it does
provide an overview of the state of LPN practice in BC.
The Changing LPN Role in B C
As mentioned in the previous chapter, several factors (i.e. shortage of RNs
and cost containment concerns) have been associated with a growing number of
LPNs being integrated/reintegrated into nursing teams in various health care
delivery settings (e.g. acute care hospital and long term care facilities)
(Greenlaw, 2003; Lantz, 2004; McPherson, 2004). In 2003, 4815 LPNs
registered with the CLPNBC (4262 renewals and 553 initial registrations
(CLPNBC, 2003). In 2005, the number or LPNs registered with the CLPNBC had
increased to 5590 (CLPNBC, 2005). As the number of LPNs employed in BC
continues to grow, so too does the number of LPNs working to their full scope of
11
practice that includes the introduction of an enhanced range of competencies
introduced by the College of Licensed Practical Nurses of British Columbia
(CLPNBC) in 2000. The result of the expanded competency areas, scope of
practice, and approach to educational preparation was a shift in the role of the
LPN from a predominantly assistant role to a role that could operate with more
autonomy and/or collaborate more effectively with other members of the health
care team (e.g. RNs) (CLPNBC, 2000). In the next section I will discuss the
changes in LPN competencies in more depth.
Changes in LPN Competencies
The issue of LPN competencies can be confusing to nurses unfamiliar with
LPN practice, as I was prior to becoming an LPN educator. In an effort to clarify
the evolving role of the LPN in BC, the CLPBC published the document entitled,
"Understanding the Role of the LPN: Entry to practice competencies for LPNs in
BC" (CLPNBC, 2000). A second publication, "Beyond entry to practice
competencies for the LPN in BC, more expert and specialized competencies for
LPNs in BC." was published 4 months later and provided a comprehensive guide
to the standards of practice and linked them with the10 competency areas for
LPNs in BC, with expectations for novice to expert LPNs outlined for each area in
a case based manner.
The 10 competency areas for LPNs in BC as outlined by the CLPNBC
include: 1) provides competent, professional care, 2) serves the public and the
nursing profession, 3) performs and refines client assessments, 4) develops
12
client-focused plans of care, 5) intervenes: puts theory into action, 6) intervenes:
communicates with clients, 7) intervenes: teaches client, verifies learning, 8)
evaluates client progress, 9) organizes care delivery for self and team members,
and 10) practices collaboratively in the health care system. These competency
areas were validated in 1997 by the National Nursing Competency Project and
later by the CLPNBC in 1998 (CLPNBC, 2000). In addition to the 10 competency
areas, in November 2000, the CLPNBC revised the role of the LPN, emphasizing
their role as care providers in the health care team and reflecting the move in
LPN education in BC away from a skill based towards a competency based
approach that included movement into the areas of health promotion and
restoration.
However, in the LPN Current Utilization Study conducted in 2003, the
competency areas selected and cited for investigation into the utilization of full
scope LPNs were those added as entry-level competencies for LPNs in 2000.
As mentioned in chapter 1, full scope practice for LPNs in BC now includes the
following 6 select competencies: a) comprehensive assessment; b) medication
administration (i.e. including administration of range doses and taking and
transcribing doctor's orders); c) wound management; d) airway management; e)
elimination management; and f) infusion management (e.g. non-medicated
infusions) (CLPNBC, 2000; CLPNBC, 2004; Greenlaw, 2003). Competencies are
"statements about the knowledge, skills, attitude, and judgment required" of the
individual LPN in order to "perform safely and ethically" within an individual's
nursing practice or in a designated role or setting" (CRNBC, 2005, p.4; CLPNBC,
13
2004). As of January 2007, LPNs in British Columbia are now required to
demonstrate knowledge and practice capabilities that cover the full range of
enhanced entry level competencies constituting full scope practice in order to
register with the College of LPNs of BC (CLPNBC, 2004). It is important to note
that not all of these 6 entry level competencies are entirely new to BC LPNs. For
example, medication administration has been included in their practice profile
since 1984 (CLPNBC, 2004). However, since that time, this competency has
been amended several times. Administration of subcutaneous injections was
added to the BC LPN competency profile in 1996. Approximately 3.5 years later,
in 1999/2000, administration of intramuscular injections was added. The range of
competencies in this category was further expanded to its current state in 2002.
This recent expansion of the medication administration competency included the
addition of: a) non-medicated intravenous therapy infusion management, b)
taking and transcribing doctor's orders, and c) "administering initial dose
medications" (CLPNBC, 2004, p. 2).
Please note that at the time of this writing, the CLPNBC was in the process of
reexamining and redefining the entry-level competencies for LPNs in the
province. No current publication has been released that details any changes to
entry level competencies. Therefore, this study focuses on the notion of full
scope practice as it incorporates the above mentioned 6 competencies
introduced in 2002 and required for LPN licensure in BC as of 2006 (except for
Medication Administration which had a deadline for completion extended to
January 2007) (CLPNBC, 2004).
14
Full Scope Practice
As I mentioned in the previous chapter, the term 'full scope' of practice refers
to the deployment of "health professionals to the full range of their roles,
responsibilities and functions they are educated, competent and authorized to
perform" (HAHPRRC, 2002, p.7). Supporting nurses (e.g. RNs, RPNs, and
LPNs) to work at their respective full scopes of practice is one of many
recommendations put forth by the Canadian Nursing Advisory Committee (2002).
However, full scope is generally a term reserved for discussions regarding LPNs
and is used to differentiate between those LPNs who meet the enhanced range
of competencies introduced in 2000 and those who do not. In light of the
enhanced range of entry-level competencies that constituted full scope beginning
in 2000, the LPN Current Utilization Study was conducted in an effort to better
understand and clarify the role of the LPN in BC (Greenlaw, 2003). The LPN
Current Utilization Study sampled representatives from managerial, educational,
and upper level nursing administrative positions from all regional health
authorities, including the Provincial Health Services Authority in BC. From the
perspective of study participants, LPNs were "being supported to work their full
scope of practice" in an increasing variety of care settings (Greenlaw, p. 20).
Plans included LPN utilization into new practice areas included emergency
rooms and operating rooms traditionally considered as specialty areas in acute
care nursing requiring advanced nursing education and preparation.
15
Utilization and Integration of Full Scope LPNs in B C
As mentioned in the previous chapter, utilization of full scope LPNs in BC has
been and continues to be inconsistent. The overall trend is to deploy an
increasing number of LPN in various practice settings across the province. While
the increasing addition of LPNs to the workforce could be determined a direct
response to the nursing shortage, in some settings RN positions have been
eliminated and replaced with LPNs (McPherson, 2004). The salary difference
between RNs and LPNs is notable but not grossly significant (e.g. starting wage
for LPN in 2007 was $22.81/hr and for an RN $26.91/hr) (BCNU, 2005; HEU,
2005). This wage difference could make the LPN role even more appealing in
settings that employed RNs and where patients care needs are equally met by
the LPN scope of practice.
Also mentioned in the previous chapter, increasing the numbers of LPNs in
staff mixes has "been met with uncertainty, fear and in some instances hostility
and resentment" from RNs (McPherson, 2004, p.3). In fact, several barriers to
LPN utilization have been identified and noted in the previous chapter. Despite
potential barriers to the utilization of full scope LPNs, the trend continues to
increase numbers of these nurses in the workforce, not only in BC but across the
country.
LPNs in Acute Care
According to Catherine Overton, former Deputy Registrar for the CLPNBC, in
2004 approximately two-thirds of the more than 4,000 registered practicing LPNs
16
in BC were employed in acute care (e.g. medical/surgical) settings (personal
communication, August 23, 2004). High acuity levels and rapid turnover of
patients in acute care, especially surgical areas, pose a challenge to utilization of
full scope LPNs for two main reasons. First, the skills in nursing assessment,
organization and management of patient care and teaching may well require the
competencies of RNs (Pamela Ottem, personal communication, August 5, 2004).
Second, LPNs provide care for clients with "...less complex care needs and
acuity as well as to clients with predictable outcomes" (CRNBC, 2005).
Therefore, the organization of patient assignments in practice environments
where patient acuity is greater and patient status potentially more unstable may
become a challenge.
A search in CINAHL yielded a sole article on appropriate skill mix of LPNs and
RNs in acute care. Clark and Thurston (1994) noted that among LPNs there was
considerable variability in their willingness to collaborate with and consult RNs in
the provision of patient care. Whether or not RNs were reluctant to collaborate
and work with LPNs in this setting was not discussed.
RN/LPN Workshops
As mentioned in the previous chapter, in an effort to clarify the scopes of
practice and role expectations of RNs and LPNs, the CLPNBC and the CRNBC
(formerly RNABC), has offered and continues to offer workshops to inform
nurses and facilitate communication between them on practice issues. Pamela
Ottem and Janice Joyce, employed by the RNABC and College of Licensed
17
Practical Nurses of BC (CLPNBC) respectively were active in their role as
practice consultants and facilitators of these workshops.
Ottem and Joyce worked collaboratively, along with additional nursing
practice consultants from both the RNABC and CLPNBC, to coordinate and
facilitate RN/LPN workshops designed to bring RNs and LPNs together to clarify
and discuss roles and responsibilities. Both of these practice consultants
observed that their members were seeking direction and role clarity, especially
as RN/LPN care delivery teams are being reinvented and full scope LPNs are
being deployed in a variety of care settings (Pamela Ottem, personal
communication, July 27, 2004; Janice Joyce, personal communication, August 6,
2004). Some LPNs have asked, "Why are LPNs replacing RNs?" (Janice Joyce,
personal communication, July 27, 2004). Meanwhile, some RNs have wondered
what the term full scope means as it applies to LPNs and what, if any, are the
limitations of full scope LPN practice (Pamela Ottem, personal communication,
August 6, 2004).
In an effort to address member concerns, the CLPNBC and RNABC have
offered facilitated workshops for RNs and LPNs in order to enhance role clarity
via mutual exploration and clarification of each others roles and responsibilities
(Greenlaw, 2003; Janice Joyce, personal communication, August 6, 2004;
Pamela Ottem, personal communication, July 27, 2004; CRNBC, 2005).
Workshops have been offered at various facilities around the province and have
been generally very well received. However, the frequency of the workshops has
been variable (Janice Joyce, personal communication, November 15, 2004).
18
Summary
In this chapter I have presented some additional background information that
serves to frame this study in the context of LPN practice to full scope in BC with a
focus on acute care settings. As a practical nursing instructor in the acute care
setting I have often been asked, primarily by RNs, "What can they (LPNs) do?"
which speaks to the ongoing confusion some RNs in acute care face when
confronted with the concept of full scope LPN practice in their workplace.
To my knowledge, there is little research-based information about the
experiences of RNs and LPNs faced with a change in staff mix involving
introduction of full scope LPNs into acute care practice environments in BC. In
the next chapter I will outline the methodology of my study and approaches to
data collection and analysis.
19
C H A P T E R III
M E T H O D O L O G Y
In this chapter I outline the following: a) the purpose of my research, b) the
methodology used in my study (e.g. qualitative description), c) the procedures
surrounding recruitment of participants, d) my initial plan for data collection and
analysis, and e) considerations of rigor. Finally, I end this chapter with an
introduction to the change I made to use surveys as the primary means of data
collection following unsuccessful attempts at recruiting interview participants. The
research question I developed sought to solicit the experiences of nurses with full
scope LPN practice, in their own words. I decided to utilize a qualitative approach
to my guide my inquiry because it fit well with my research question and desire to
gain an understanding of the unique perspectives of nurses.
Qualitative research strategies are oriented to aid the researcher in seeking
answers to "questions that stress how social experience is created and given
meaning" (Denzin & Lincoln, 1994, p.4). In my view, therefore, qualitative
research strategies can provide a richer, more in-depth understanding of nurses'
and full scope LPN practice than quantitative methods. I wanted to fully explore
the experiences of RNs and LPNs, and this would have not been possible with a
quantitative approach because in my opinion, a quantitative approach would not
have allowed me the opportunity to respond to the data and explore emergent
concepts fully, as is possible with a qualitative approach.
20
Purpose
"The question posed in this study is: "What is the experience of registered
nurses and licensed practical nurses working with or as full scope LPNs in the
acute care setting?", with a focus on BC. What follows is a description of what I
originally proposed and set out to do to explore the experiences of RNs and
LPNs. It will soon become evident that my study did not progress as planned
and in fact required a major change in my approach to data collection. This does
not detract from the thesis' rigor. Maxwell (1996) has indicated that subtle
adjustments (or major adjustments, sometimes) are needed when undertaking
qualitative research projects. Details of the changes made, rationales for change,
and outcomes will be discussed further in chapter 4 as the circumstances
surrounding the changes served to inform my inquiry.
Qualitative Description
In order to explore the experiences of RNs and LPNs, and following
consultation with my supervisor, I decided to engage in a small scale, qualitative
descriptive study. To my knowledge, nurses' experiences of full scope LPN
practice in acute care in BC have yet to be documented in the literature.
Qualitative description is one approach to qualitative research aimed at
discovering a "straight descriptive summary" of a phenomenon of "special
relevance to practitioners and policy makers" (Sandelowski, 2000, p.338, 337). In
fact, it is considered by Sandelowski to be, "the method of choice when straight
descriptions of phenomena are desired" (p. 339).
21
Other established qualitative approaches such as ethnography,
phenomenology, and grounded theory can be used to address questions
pertaining to experience. However, the degree of depth and interpretation
generally required to conduct a comprehensive ethnography or
phenomenological inquiry surpassed the scope and primary intent of my study.
Phenomenology, ethnography, and grounded theory are generally more
interpretive in nature than needed for an introductory inquiry into a relatively
unstudied topic. Ethnographies typically involve more immersion into the field of
study and culture of interest with the average number of participants ranging from
25 to 50 (Polit & Hungler, 1999). Also, ethnographic analyses are often aimed at
describing cultural behaviours, revealing social patterns or observed conduct
(Morse & Field, 1995; Polit & Beck, 2004). As I did not set out to identify patterns
or observable patterns of conduct and given the general scale of a typical
ethnography, I did not find that this methodology was best suited to my question.
Phenomenological inquiries involve a reductionist process aimed at isolating
the essence and meaning of a lived experience and revealing critical truths about
reality that are grounded in personal experiences (Morse & Field,1995; Polit &
Beck, 2004). Phenomenological inquiries can be descriptive or interpretive, but
both aim to provide a rich description of the essence of a particular lived
experience. Again, while my area of interest might be amenable to a
phenomenological inquiry, the depth and breadth of such an inquiry surpasses
both my overall aim at attaining an introductory understanding of nurses'
22
experiences and the limited time and resources available for my study (Morse &
Field,1995; Polit & Hungler, 1999)
The inductive nature of qualitative description can be useful in providing a
description of a phenomenon in terms that are meaningful and relevant to those
experiencing it (Sandelowski, 2000). Perhaps maligned by some researchers
who view it as to simplistic, Sandelowski observes that many research studies
undertaken under the guise of phenomenology, grounded theory, and
ethnography in fact more accurately utilize qualitative description method albeit
with undertones of the aforementioned methodologies. In discussing qualitative
description, Sandelowski highlights the utility of the method as a basic, effective,
and low inference approach to answering research questions seeking to find "a
comprehensive summary of an event in the everyday terms of those events" (p.
336). Undertaking a study using qualitative description is akin to a fact-finding
mission aimed at providing a "minimally theorized or otherwise transformed"
rendering of data in terms that stem from the data themselves (p. 337). However,
qualitative description does not simply end with a rendering of facts. The
researcher has a key role in qualitative description in identifying key categories in
response to a particular question and also recognizing and describing latent
meaning attributed to the experiences.
In studies using qualitative description the researcher recognizes the
significant role they play in determining the final nature of the product (i.e. an
informed description of the subjective experiences of participants). In my case,
my background as an RN and practical nurse educator in various acute care
23
settings provided a lens through which I examined the data and ultimately framed
my final description.
Recruitment
Initially, I set out expecting to interview approximately 10 nurses (an equal mix
of RNs and LPNs) who work in one of 4 acute care units in a large Lower
Mainland hospital where the LPNs practice to full scope (as of March 2006). As it
turned out I was able to engage 9 participants in total. Only one was confirmed to
work in the original setting specified above. The 6 additional participants joined
the study by responding to anonymous, mail-in surveys (Appendix VI). While I
ended up with a mix of RNs and LPNs, I was unable to confirm the specific units
or facilities where these nurses practiced. Details of the switch in data collection
method will be discussed further in this chapter.
I completed the UBC Behavioural Research Ethics Board approval form in
March of 2005 and obtained approval by May of 2005 (Appendix I). I then
completed the research approval request form for Vancouver Coastal Health
Research Institute in March of 2005 and obtained approval to proceed by May of
the same year. Sandelowski (2000) suggests purposive sampling, especially
"maximum variation sampling", for qualitative descriptive studies (p.337). Initial
recruitment efforts employed convenience sampling (i.e. whoever responded to
the study notices) in order to gain an initial base of participants and data that
would later guide my purposeful sampling as the study progressed. Purposeful
sampling would have enabled me to obtain data from a variety of nurse
participants, for example, if only young RN graduates with no previous work
24
experience with LPNs responded I might then try to recruit RNs with more
extensive and longer practice histories that included past work with LPNs. The
idea behind purposive sampling, in particular maximum variation sampling, is to
gain a broad understanding of an event or topic from a variety of unique
perspectives. Therefore, my initial recruitment approach seemed like a solid plan
that would result in more then enough participants. Numerous nurse colleagues,
students, former students and bedside nurses, to whom I mentioned my study
topic in the months leading up to the actualization of my study, expressed a
keen interest in either participating or supporting my research. I was encouraged
by the interest and positive feedback I received and entered into the recruitment
phase of my study with a good deal of confidence that I would receive more then
enough interest in my study, so much so that I would in fact be able to conduct
purposive sampling.
My initial recruitment efforts sought nurses who were employed on 4 surgical
units at the selected acute care hospital facility where the LPNs had been
practicing to full scope on their respective units for approximately 6 months. A
total of 10 recruitment notices (Appendix II) were placed throughout the 4 units in
June 2005 in various "high traffic areas" (e.g. staff bulletin boards, staff lounges,
and staff washrooms). Following posting of the study notices only 3 study
inquiries were received.
I also planned to introduce my study at staff meetings organized by unit
managers. This latter approach to advertising/recruitment did not occur however
as the meetings were repeatedly rescheduled or cancelled by the managers (e.g.
25
'not a good time', 'too busy', manager on vacation). After close to 2 months of
unsuccessful attempts at rescheduling meetings (i.e. coordinating unit manager
and staff availability and my own full time work schedule) and facing a particularly
busy time at work, personally, no further attempts were made.
By October 2005, following a) a prolonged period of no responses to study
notices; b) ongoing delays and rescheduling attempts with unit managers to
speak at staff meetings on the units; c) a prophetic statement from my single
interview participant that I was unlikely to receive any other interview participants;
and d) following consultation with my supervisor, a decision was made to change
the method of data collection. Anonymous, mail-in short answer surveys were
constructed using 6 of the original 9 interview questions and coupled with the
demographic form (Appendix V) utilized with the initial interview. Over the next 3
months batches of anonymous, mail-in surveys were distributed to unit managers
and colleagues who requested and /or offered to distribute them to nurses they
knew personally who either worked on the 4 units at the selected acute care
facility or in other acute care facilities where the LPNs worked to full scope. In
total 36 surveys were distributed and 8 were returned completed for a response
rate of 22 percent. One survey was returned intact and completely blank and as
such is not included in future discussions of the surveys. Since the surveys were
distributed by hand, from acquaintance to acquaintance, I assumed that the
response rate would have been considerably higher and was quite stunned to
see once again that few nurses decided to participate. The notion of resistance to
participation is discussed further in the next chapter.
26
Procedures
In this section I will describe my approach to data collection and analysis as I
originally intended. I will also present my considerations of rigor for this study. I
will then outline what constituted my audit trail for this study. Finally, I will present
the circumstances and details surrounding a change to using short answer
surveys as my main method of data collection.
Data Collection
I planned to collect data using approximately 10, single, one hour, semi-
structured, open-ended interviews and a brief demographic form (designed
primarily to facilitate purposive sampling) with each participant. Informed
consent was to be obtained prior to beginning an interview (Appendix III). The
interviews were to employ a short interview guide, consisting of 9 open ended
questions that I developed to aid in focusing and standardizing my inquiry on the
experiences of nurses (Appendix IV). My construction of the 9 interview guide
questions was influenced by Charmaz's (2002) suggestions for how to construct
a qualitative interview guide. The questions were broad enough to solicit a wide
range of participants' experiences of full scope LPN practice in acute care, but
also focused enough to keep data collection in tune with the objective of my
inquiry. Questions were going to be modified as needed, on an ongoing basis,
based on findings from data and preliminary analysis of each interview.
I also intended to draw upon collateral data sources where possible (e.g.
personal communications with nursing practice consultants, unit managers,
discussions with nursing colleagues, and observations of the transition to full
scope LPN practice in acute care settings where I have work experience as an
LPN educator), to add additional richness to the context of the nurses'
experiences/statements. This collateral data helped to inform my discussion of
my findings and I will discuss this further in chapter 5. Finally, I kept anecdotal
and reflective notes throughout my process of recruitment, data collection, and
data analysis as a means of laying out my own experiences and thought
processes as I moved forward in the research process. This reflective process
not only served to guide my later analysis of the data, but also helped to direct
my changes in data collection approach and management (e.g. the shift to
surveys).
The main, initial data collection techniques I selected (semi-structured
interviews & use of collateral data sources) were selected following a review of
Sandelowski's (2000) article on qualitative description in which proposed
techniques for data collection for the method were outlined. In the article,
Sandelowski suggests data collection techniques that seek a "broad range of
information", such as, "minimally to moderately structured interviews and/or focus
group interviews" (p. 338). In addition, other data gleaned from observations and
review of print materials is proposed to be useful in studies employing qualitative
description. Even the switch to short-answer questions in the survey later in the
study was not, in my understanding, a massive departure from suggested data
collection in qualitative description since it used the same open-ended, interview
guide questions and included a question which encouraged participants to add
28
any additional information they felt was relevant, if not covered in previous
questions. However, I will discuss the shift to surveys and the surveys
themselves in more depth in chapter 4.
Data Analysis
My initial plan was to proceed with data analysis concurrently with data
collection. As mentioned previously, I also planned to modify the interview guide
as needed as I progressed with the interviews and analysis in order to better
flesh out themes/categories identified in each previous interview or potentially
identify new themes/categories. Content analysis would be used to analyze the
interview data as recommended by Sandelowski (2000) in outlining qualitative
description. Additionally, I kept anecdotal notes and a reflective journal to further
facilitate my analysis.
All interviews were to be transcribed verbatim and then reviewed in depth.
Demographic information was to be catalogued and used to facilitate purposive
sampling as the study progressed. Ultimately, my aim was to discover a series
of categories or themes that were directly reflected in the data and best captured
and described the experiences of RNs and LPNs of full scope LPN practice in
acute care. This was my plan. However, in the case of my study as with many
things in life even the best of plans can sometimes require adjustments and this
approach had to be modified as I have mentioned previously and will discuss
further in this chapter and in the next.
29
Content analysis. Qualitative content analysis is the analysis strategy
recommended by Sandelowski (2000) for qualitative descriptive studies. This
approach is the "least interpretive of the qualitative analysis approaches" and is
aimed at representing the data (i.e. both the explicit and implicit meaning of the
data) in its own terms (Sandelowski, p.338). Sandelowski cites Altheide who
discusses ethnographic content analysis and highlights the central position of the
researcher in relation to the data. The process of qualitative content analysis is
inherently "reflexive and interactive" (Sandelowski, p.338). Through a process of
constant comparison and continual discovery the researcher employing
qualitative content analysis visits and revisits the data, identifies categories and
generates a straight, "narrative description" that includes both the explicit and
latent content of the data ( Sandelowski, p. 74). Since Altheide's discussion on
ethnographic content analysis, general qualitative content analysis has been
described in even greater depth. With the aim of facilitating the researcher's use
of this analysis strategy with enhanced clarity of approach and purpose, Hsieh
and Shannon (2005) outline 3 forms of qualitative content analysis (conventional,
directed and summative).
Conventional qualitative content analysis is differentiated primarily from
the other two types of qualitative content analysis in that the initial codes and
categories are derived directly from the data rather than from existing research,
theory and literature. For the purposes of my inquiry, therefore, conventional
qualitative content analysis was selected as the analytic strategy to best answer
my research question.
30
Criteria for Affirming Rigor
To ensure rigor in qualitative research is to ensure research is conducted in
such a manner that errors are avoided and findings can be considered
trustworthy and believable (Koch & Harrington, 1998; Lincoln & Guba, 1985.
Lincoln and Guba outline four criteria for evaluating trustworthiness that are
applicable to qualitative research, 1) credibility; 2) applicability; 3) auditability;
and 4) confirmability. Using guidelines for rigor outlined by Sandelowski (1986)
and Lincoln and Guba, several steps were taken during my research process to
ensure issues of rigor, particularly auditability and credibility, were addressed.
Auditability
Trustworthiness in qualitative research is fundamentally concerned with
making the research process visible and traceable (Sandelowski, 1993).
Auditability is the term applied to the process or steps involved in delineating the
research process and decision making process therein (Beck as cited by Koch &
Harrington, 1998). Several steps were taken to address auditability in my study,
from it's initiation to conclusion, thereby making my decision making process
visible and traceable. For example, details of the sampling process, specifically
the initial approach taken and subsequent changes, are outlined in Chapter 4.
Five main processes surrounding data collection and management I employed
during the course of the study are also outlined, These 5 processes included: 1)
use of a predetermined interview guide to help guide the single, semi-structured
interview; 2) consistently applied analytic techniques (e.g. coding method, use of
31
marginal notes, and colour coding system) when reviewing the interview
transcript and later survey responses; 3) ensuring working definitions of analytic
terms (e.g. codes and categories) are provided; 4) checking in with my thesis
supervisor at intervals to help ensure my decision making process remained
visible and logic in the inductive reasoning process remained clear; and 5)
keeping a reflective journal for the duration of the research process which served
as a sounding board for my thought processes throughout the process of data
collection and management, not only the 'how' but also the 'why' of my decision
making processes.
Credibility
Credibility refers to the believability and relevance of the research conducted
(Lincoln & Guba, 1985). Several steps were taken to ensure credibility in my
research. In an ongoing fashion, I checked to ensure that my analysis was data
driven by reviewing my codes and categories while reflecting back on the data as
a whole. To facilitate this process I kept a journal where I noted my progress with
category and code development, my impressions of the data and how reflective
of the data, or not, the codes and categories seemed as subsequent surveys
were received and reviewed. In this manner of ongoing reflection and taking time
to step back from my coding to review the data as a whole, I was able to further
develop and refine my categories.
I also discussed my developing categories with my thesis supervisor at
intervals as I proceed with the analysis. In addition I challenged and refined my
conclusions by returning to the data and seeking both similarities and differences
to ensure that my conclusions indeed made sense and remained relevant to the
data. This process of challenging and refining my conclusions was aided by
checking them with my thesis supervisor at intervals to ensure my inductive
reasoning process remained logical and visible.
My Audit Trail Discussed. What follows is a description of the processes
undertaken by me during my research. It is important to note that the single
participant interview obtained and subsequent 8 surveys returned were treated
as independent data initially and only in the latter stages of analysis did I look to
compare and contrast categories from both sets. The process of shifting to
surveys is an important part of my research which is discussed later in this
chapter and further in Chapter 4.
The single interview was conducted with the use of my interview guide and
was later transcribed verbatim. The transcript was then read while concurrently
reviewing the original interview audiotape in order to ensure accuracy of the
transcribed data. Following the first read, the transcript was read through in its
entirety again, at which time I highlighted keywords and/or phrases using colored
pencils and marginal notes. Initial codes identified constituted "primary
categories". These primary categories were numerous initially and were later
refined and combined, as I continued to immerse and reimmerse myself in the
data, in order to obtain a more concise and yet relevant summary of the
participant's responses.
33
Survey responses were transcribed verbatim onto my computer and collated
into a single document. The survey data was reviewed and coded in a similar
fashion as was the interview transcript, however, I did not seek to confirm or
disconfirm categories found in the interview data as I sought to treat the survey
and interview data as distinct in the preliminary phases of my analysis.
Combining data sets and treating them as a single grouping would have been
inappropriate as there was much difference in the manner of data collection and
data received.
Categories identified in the interview and survey data and the substance and
nature of subsequent revisions to categories were tracked by date and marginal
notes and later, in my reflective journal. Also, collateral data obtained (e.g. my
experience trying to organize unit information sessions for my study; my
experiences with prospective participants on that unit; staff postings on an acute
care unit implementing full scope LPN practice; anecdotal information from
nursing colleagues; and information from articles) were recorded in a reflective
journal as I proceeded.
Once I identified several key categories in each respective data set, I then
looked for similarities and differences among/between interview and surveys,
recognizing that I was dealing with two distinct data sets, speaking to a common
topic. Ongoing reflection on the processes of analysis and my own biases in my
reflective journal helped to keep my research process transparent. Keeping my
reflective journal helped to provide me with a "critical gaze" on the analytic
processes undertaken and to enhance their defensibility by providing an audit
34
trail of my research process (Koch & Harrington, 1998; Thorne, Reimer Kirkham,
MacDonald-Emes, 1997). Meetings with my supervisor at intervals also helped
to advance my research in a logical and transparent fashion that helped keep me
accountable to the research process and true to the data.
The Shift to Surveys
In the 4 months following the initial interview no further study inquiries were
received that resulted in an interview. The study unfolded radically different from
what I had expected. Plans for data collection and analysis were no longer
meeting the needs of the study. In effect, data collection had ground to a literal
halt and the proverbial clock was ticking. As a result, and in consultation with my
supervisor, I reworked my initial plan for the study (i.e. recruitment and data
collection approaches). This decision to switch my focus from single interviews
to anonymous, mail-in surveys using 7 of my original 9 interview guide questions
as the main method of data collection was made for several reasons which will
be detailed in Chapter 4. I submitted a proposal to the UBC Behavioural
Research Ethics Board for approval of a change to surveys in October of 2005
and obtained approval by November of the same year.
CHAPTER IV
Data and Analysis
The nature of my question
My research question was, "What is the experience of registered nurses and
licensed practical nurses working with or as full scope licensed practical nurses
in the acute care setting?". In essence, I wanted to know how nurses who are
living this rather 'new' phenomenon first hand are experiencing it. The impetus
for my question stems from my work as a registered nurse with an acute
care/critical care background and more recently as a practical nurse educator. I
am actively involved in the education of practical nurses in the acute care
component of their education at the college where I teach and have been curious
as to how both RNs and LPNs are experiencing the implementation of full scope
LPN practice in the acute care setting.
My question was deliberately broad in nature because it is, to my knowledge,
the first inquiry of its kind to focus exclusively on the experiences of nurses with
full scope LPN practice in acute care in British Columbia. My question was well
suited to qualitative description method as this method is, "especially amenable
to obtaining straight and largely unadorned answers to questions of special
relevance to practitioners and policy makers" (Sandelowski, 2000, p. 337).
What Happened: A Chronology
The time of the study coincided with a heavy time at work for me personally,
therefore my research process which began in the spring of 2005 concluded in
36
winter 2007. Soon after I entered the recruitment phase of my study, it became
obvious to me that there were significant impeding factors influencing my
attempts at recruitment. I was surprised by the low response rate to my study
notices. I considered the apparent reluctance to participate as data to consider in
and of itself, particularly as the one interviewee predicted that no-one else would
volunteer. What follows, is an account of how my research process unfolded for
me beginning with the posting of study notices in June of 2005.
Initial recruitment efforts
Once I received approval to proceed with my study from the ethics board of
the selected hospital site in March 2005, I approached the unit managers to
introduce myself and proceeded to post a total of 10 study notices. Surprisingly,
in the four months following the posting of study notices, I received only 3 queries
regarding my study and only 1 resulted in an interview. This was entirely
surprising for me, as many nurses with whom I discussed my research with in
casual conversation, prior to initiating recruitment, all made comments to the
effect that they thought this was a good and timely topic and that I was sure to
have a lot of responses. In chapter 3 I outlined my subsequent change in
recruitment and data collection techniques to anonymous, mail-in surveys
delivered by hand to prospective participants by unit managers and personal
work colleagues. Thirty-six surveys were distributed in total and each survey
packets contained: a) a 3 page survey using 6 of the 9 original interview guide
questions, b) a demographic form, and c) a stamped, self-addressed envelope.
37
Below, I provide summary information on the 9 nurses who ultimately participated
in my study (e.g. 1 interviewee and 8 survey respondents).
Participants
In total, 9 nurses participated in my study (4 LPNs, 5 RNs). The single
interviewee was an LPN. One person mailed in all survey documents blank and
as such is not included as a participant. This submission of a blank survey was
fascinating to me as it showed someone took the time to fold the survey and
accompanying documentation, lick and seal the envelope and find a mailbox
while providing no information whatsoever. This person's non-response response
was unique, thankfully. To facilitate my discussion on the survey responses in
this chapter, however, I will now only refer to those surveys that were submitted
complete (002-009).
Completed surveys submitted were anonymous therefore the details of who,
in particular, provided the respondents with a survey and what was said to the
respondent about the study at the time they were given a survey are not known.
However, I assume the respondents acquired their surveys directly from one of
the managers or colleagues I provided batches of surveys to. Also, it is not
known whether or not the survey respondents work at one of the 4 specific units
initially the focus of my recruiting efforts since packets of surveys were
distributed to some of my work colleagues as well as the unit managers of the 4
units at the selected acute care facility. All study participants were female and all
but one received her nursing education in British Columbia.
3 8
The participants ranged in age and years for nursing experience. The LPN
participants were generally older (i.e. >35yrs), however one LPN who responded
did not state her age. The RN participants ranged in age from early twenties to
mid-thirties. Years of nursing experience spanned a wide range among all
participants (e.g. 1 - 25 yrs). However, overall the RN participants had less
practice experience overall than the LPN participants. Only 1 survey participant
failed to include her/his length of nursing practice. All but 2 participants
acknowledged nursing experience in more then one type of practice setting (e.g.
sub-acute medicine, long term/extended/intermediate care, hospice, clinics, and
emergency). Two participants (1 RN and 1 LPN) had attended the joint
CRNBC/CLPNBC RN/LPN workshops.
As I mentioned in the previous section, despite posting numerous study
notices and hearing casual expressions of interest in my study from a number of
nurses and colleagues, I only interviewed one nurse. What follows is a summary
of the 3 expressions of interest I received from nurses regarding my study once I
posted my study notices. Following that, I present my analysis of the interview
data.
Three expressions of interest: one interview
The first query of interest in my study came from a RN who spoke with me
while I was placing the study notices. This RN expressed a keen interest in
participating in an interview with me, giving me her telephone number and
inquiring if she could set up an appointment on the spot. She told me that the
39
presence of the LPNs on her unit has led to much stress for her and 7 5 % of the
other RNs. She added that working with an LPN causes her to be more scattered
due, in part, to the frequent questions she receives regarding LPN patients from
LPNs and physicians. Also, she stated that the LPN presence was "confusing for
patients" since she would need to administer some medications (e.g. IV
medications) for the LPN's patients that the LPN could not deliver since the
action falls beyond the LPN scope of practice. During our conversation, I also
overheard some RNs joking with each other that there are a number of RNs
leaving the unit "because they don't want to work with LPNs" then the RN I was
speaking with added, "just kidding".
I casually mentioned that I used to teach RNs and now teach LPNs. She
reacted with visible surprise and then offered to post study notices in the break
room and bathroom. Conversation changed to social matters briefly until I asked
her if she could explain how the nursing assignments were set up on her floor.
She explained the assignment structure to me briefly and added that some LPNs
are great and others are not. She said that working with some LPNs is better
when she can delegate well. She added that RN workloads are often heavier
when working with an LPN and "at the end of my shift I get home just exhausted".
Finally, she mentioned that the hospital nametags only use the title "nurse" and
not "registered or licensed practical nurse" and that this lack of distinction was
not welcome (e.g. by RNs and some patients). Apparently needing to get back to
work, we set up an interview for the following week; however, she did not return a
40
planned confirmation call the morning of the scheduled interview and I did not
hear from her again
The second inquiry came from a nurse who later became participant #001. In
fact, this nurse contacted me to see if my study was connected to some project
or study the CLPNBC had called to invite her to participate in back in March
2005. She had not received any further information from the CLPNBC and hence
decided to call my study contact number. I was confused when she contacted me
initially, since I had not heard of (nor have heard of since) any proposed or active
inquiries being conducted by the CLPNBC. I explained my study to her and I was
invited to her home for an interview. This nurse was extremely forthcoming with
her experiences as a LPN practicing to full scope on her unit at the acute care
facility. This interview was transcribed verbatim and later analyzed; the analysis
and results will be discussed later in this chapter. During the interview, this nurse
did express that for a number of reasons (e.g. cultural background of a number of
fellow FSLPNs at the hospital) I would probably not have many or any further
interview participants, strangely enough, her words were prophetic.
The third and final inquiry into my study came in early September 2005 from a
LPN who was not an employee on the study units, but was in fact considering
employment there. She stated that she had seen my study notices and that the
purpose of her call was to find out what I knew about the unit as she was
considering applying for a casual position there. This nurse wanted to know
whether or not I felt the unit(s) in question was/were a good place for LPNs to
work and what I knew about the transition (e.g. to full scope). I was quite taken
41
aback by this. She sounded disappointed when I told her my research was for my
thesis and was not a program evaluation. She stated that "the system
(healthcare) is sick", with too many experienced nurses retiring, too few RNs
emerging from the 4 year programs, and too many LPNs coming out of the 12
month programs with fewer and fewer mentors.
She also stated that she finds that LPNs are often working beyond their
scope of practice out of necessity and that she has hope for, but worries about
the younger, newer nurses who don't have experience to draw from. Finally, she
stated that the transition to full scope practice in her current workplace was not
without growing pains and that "I've already been through that...I don't want to go
through that again". She was not interested in participating in the study and when
she realized that my research was not a program evaluation for the unit promptly
ended the telephone discussion.
As I mentioned earlier in this chapter, following the posting of my study
notices only one expression of interest resulted in an interview. In the following
section I present my analysis of the interview.
Analysis of Interview with Participant 001
The first and only interview participant in my study approached me in the
spring of 2005. As an LPN working on one of the four units I posted study
notices on, this participant was eager to speak with me and during my one hour
interview with her she recounted numerous examples of her personal views and
her experiences working to full scope in acute care. Following my initial reviews
42
of the interview transcript, and using the procedures for analysis described in
Chapter 3, to address the research question, "What is the experience of
registered nurses and licensed practical nurses working with or as full scope
LPNs in the acute care setting?", I identified 8 categories.
These eight initial categories were: 1) critical thinking, 2) communication, 3)
isolation, 4) survival, 5) receptivity, 6) recognition/respect, 7) identity, and 8)
appropriateness. After a period of a few weeks, during which time I was working
on other things, I returned to the interview and my eight categories to review
them and the supportive quotes I had identified for each. Some categories
required change while others still seemed appropriate to me. For example, the
category entitled critical thinking seemed too narrow, especially in light of
comments this participant made when discussing critical thinking and how this
participant felt hers was being questioned by some RNs on the unit. What this
participant seemed to be saying, when I looked at the context of her comments,
was that she felt her professionalism or abilities as a nursing professional were
being questioned. In later comments this participant provided specific examples
that, in my view, asserted her professionalism, such as how she managed
emergent patient care situations without support from her buddied RN and
identified several RN medication errors. In light of this I changed the category title
to professionalism. In my discussion of the category oi professionalism I will
provide examples further illustrate that professionalism is a more fitting category
then solely critical thinking.
43
Further reflection on my modified category and remaining categories led me
to believe that my analysis could be more concise. In other words, I could reduce
the number of categories while still capturing the essence of what this participant
was saying in her interview. After careful consideration and ongoing immersion in
the data and my analysis, I reviewed and consolidated my 8 previous categories
into 3 key categories that appeared to typify her experiences. These 3 categories
are: 1) professionalism, 2) receptivity, and 3) appropriateness/fit. Each of the 3
categories is discussed below; supporting quotes are included that best
exemplify each category.
Professionalism
The theme of professionalism stemmed from a number of comments made by
this participant whereby she expressed feeling that her professionalism and even
at times her professional identity were being challenged and/or undermined by
RNs and unit management. She also made comments which seemed to affirm
and assert her professionalism and professional identity. For the purpose of this
analysis, therefore, professionalism refers to actions and characteristics of a
professional. The initial categories of critical thinking, identity, and some aspects
of communication all served to inform this category of professionalism. This
category is presented in terms of professionalism challenged and
professionalism asserted.
Professionalism challenged. This participant made a number of comments
which in my view demonstrated that she perceived some RNs as challenging or
questioning her professional capabilities and competencies as a nursing
professional, in effect possibly viewing her as a lesser professional. One of the
first observations she made was that not only some, but many RNs question the
LPNs ability to think critically in the clinical area; "for some reason there's a belief
with a lot of the RNs that, um, that we are not trained as critical thinkers and that
we shouldn't be there because we couldn't possibly think it out".
In addition to making the comment that RNs questions LPNs ability to think
critically, she gave a specific example of an incident where she felt a RN
challenged her critical thinking and professionalism and directly undermined her
to her patient.
Here she is referring to an incident where an RN directly questioned her
professionalism (i.e. how she responded to a patient's Foley catheter clamp
coming loose and leaking urine onto the floor). The LPN stated that she stood in
the doorway. Behind the RN when she heard the RN stating to the patient, "well
she didn't do a damn thing for you did she?". The same RN then allegedly
proceeded to report this participant to her manager with a story of improper
nursing care that was not accurate, according to this participant. Unit RNs
approaching unit management with allegedly unsupported complaints of her own
and other unit LPNs' practice, and unit management acting in favour of the RNs
is a recurrent issue discussed by this participant; "and it is abuse, you're not paid,
anyone is not paid to take that in their job."
4 5
Along with comments regarding how she feels LPNs' abilities to think
critically in practice is challenged by some RNs, she also stated that RN mistrust
of LPNs (e.g. competencies and capabilities, including critical thinking ability) is
directly to blame for lack of inclusion of LPNs in nursing teams in some acute
care units in her facility.
I understand that they decided to take the full scope LPN out of there again even though they had just put them in. Now I don't know the reasons exactly why but what I have heard is that some of the LPNs were doing a fantastic job and were trusted and some were not and that's not a part of the reason, it was the reason they decided to take them out. Now I don't know exactly if that's true or not...
Here she was speaking about another acute care unit she was worked in,
at full scope, a few years prior to joining her present unit. Along similar lines,
during a conversation I had with one of the unit managers for one of the four
units where I placed study notices, I was told about an incident on another acute
unit in the hospital in which an LPN allegedly did not report a significant,
physiological patient finding to her buddied RN until the end of her shift. Her
manager used this as an example of how the LPNs were not necessarily reliable
in reporting or perhaps even recognizing important, reportable patient findings in
a timely manner.
Another example of how this participant felt that LPN professionalism in
general is challenged or undermined was highlighted when she talked about the
seemingly arbitrary distinctions regarding nursing skills/ tasks that are designated
for RNs and LPNs in units where she has worked.
I worked there initially and it was all full scope many LPNs there actually, um, and we would give sliding, sliding scales insulin...and then it was decided oops, can't do that, its too, its too, uh, patients are too acute but it
4 6
kind of made me laugh because in my experience in long term care many people's standard way of receiving insulin is sliding scale so it doesn't always necessarily mean that the patient, often too on surgical floors, I know on (specific unit) our surgeons as soon as they came in, they'd be taken off regular insulin and put on sliding scales until they had their surgery, until they were stable, so its ironic that the powers that be have judged it as a duty that we can't do because it doesn't make sense.
She again commented on seemingly arbitrary distinctions between LPN and
RN tasks when she stated the following.
It was very specific points that were, at which point does it become a patient that only the RN can look after... it was a very initial list I remember looking at it and it made actually no sense because what they do is they would still give us the patients with the sliding scales. We could take the glucometer, we'd just have to grab an RN to do that so if you're telling us the patient is too acute then the patient is too acute, you can't have it both ways and this is the kind of stuff that ... still is, it hasn't changed.
This observation on her part is similar to one that I had when I first took a
student group to a sub-acute medical ward in the same hospital facility in 2003.
There was a list of skills that excluded LPNs even though they fell within the
scope of LPN practice as outlined by the CLPNBC. Now in retrospect, that unit
had only recently started utilizing LPNs to full scope and this list was most likely
to be reviewed once implementation was more established. However, it did seem
like a rather arbitrary list on first reading and was a source of confusion for both
myself and my students initially.
Professionalism asserted. Perhaps in response to her recounting
experiences where she felt criticized by RNs, this participant proceeded to make
statements that seemed to me to assert her professionalism in several ways.
47
First, she asserted her capacity to think critically by questioning the same ability
in her RN critics (e.g. recent graduates who are younger and might still live at
home).
we have our critical thinking and that, that's a real thorn in my side is the critical thinking thing, my god, ...but for some reason there's a belief with a lot of the RN's that, um, that we are not trained as critical thinkers and that we shouldn't be there because we couldn't possibly think it out or, you know, and, and that's something that doesn't just come with education, that's something that comes with training and it sort of comes with upbringing, um, and I think if you're living out on your own through life, you become a critical thinker and I find that quite often the people that use that terminology were still living at home [laughter] and hadn't worked before, hello, how critical has your thinking been?
Second, she reflected on her own broad range of previous experiences and
the fact that she has been practicing to full scope for some time prior to her
present position; "I am from (a location outside ofBC) and they've upgraded
some time ago and they still are, still are, you know, adding different areas but so
I was initially hired in 2002 full scope".
...I guess, at (this hospital) some people had to go back to school, well I didn't have to do that because I had that in my course and because I'd gone back in (early 1990's) and gotten a four month pharmacology so I was already up there, um, but what they did do is they increased my duties into the full scope.
Third, she commented on her experience catching/recognizing errors in
practice made by RN colleagues; "But you know, the other night how many med
errors I found on my shift, three all made by RN's", and "so while they're running
around pointing their fingers, picking and going on and on, their own practice is
going to be affected too".
Fourth, she gave a detailed example of how she managed an emergent
patient situation (and assumed a leadership role) with little to no support from her
48
buddied RN on the unit or other unit RNs. In this experience she recounted, she
spoke of how she was forced to manage the care of two patients who became
critically ill during her shift. These 2 patients were no longer stable, their
outcomes no longer predictable and therefore fell beyond her sanctioned scope
of practice. However, when she attempted to change assignments with her
buddied RN she was told to "f*** off' and how it "it must be f***ing nice for you
LPNs to give up your patients the minute they get hard" (e.g. become acutely
ill/unstable). She spoke of how she then collaborated with a float RN to
coordinate and manage the care of these 2 patients until the end of her shift
In addition to this participant giving examples which demonstrate her efforts to
assert her own professionalism, she also spoke of her professional identity as an
LPN and how RN attitudes towards LPNs need to change. She also expressed
pride in her identity as a LPN.
RN's need to get off their hoity toity throne and realize that LPNs are trained competent professionals just as they are and that, in fact, a lot of their behavior proves that four years university doesn't mean shit because they're not showing what they should show based on education, just on education alone, that's all that matters to them, um, so having said those two things, they also have to learn to work with each other and to be less harsh on each other, they're hard on each other particularly hard on us because they see us as lower end of the food chain and that has to change. I've had people say to me well aren't you going to become a nurse and I'll say, I'm a licensed practical nurse, I am a nurse I don't want to be an RN, if I wanted to be an RN I would become an RN.
In summary, this participant offered several examples and personal reflections
that in my view spoke to the notion of professionalism. In the next section I will
discuss the category of receptivity.
49
Receptivity
The category of receptivity was generated upon further reflection on the
interview transcript and reflection on the initial categories of: communication,
isolation, survival, and recognition/respect. The experiences discussed by this
participant that led to my generating the aforementioned 4 categories, upon
further reflection, all seemed to speak to the larger point of receptivity. For
example, the initial category of communication, included comments from this
participant regarding how she felt some RNs were unwilling to include her in
conversations regarding patient care and how she felt misunderstood by some
RNs. Further reflection on the comments regarding communication with RNs I
was struck by the idea that some RNs were not receptive to communication from
this participant. The other initial categories (e.g. isolation, survival, respect, and
recognition) all included comments that indicated this participant did not feel
neither she, nor the other LPNs in some cases, were being welcomed, supported
and/or included in the unit. Receptivity herein refers to the willingness to include
and accept both the presence and professional contribution of this participant on
the unit. The overwhelming sense I got from the interview with this participant is
that, from her perspective, neither the facility nor staff (e.g. RNs and unit
management) were very receptive to the arrival of full scope LPNs on the unit. As
a result, this participant recounted feeling quite marginalized.
For the purposes of this discussion, I will expand on the category oi receptivity
by presenting examples that highlight this participant's overriding thought that
there is a lack of receptivity in her workplace towards not only her but to the
50
presence of other LPNs now practicing to full scope. I will also provide a couple
of instances where she gave specific examples of particular individuals who, in
her opinion, were more receptive to herself and other LPNs; however, there are
very few examples. Finally, I will present her suggestions for how receptivity in
her workplace could be enhanced and would in turn improve working conditions
for herself and potentially other LPNs in her facility.
Receptivity: a lack thereof. This participant cited numerous examples and
personal experiences which, in my opinion^ can be interpreted as examples of a
lack of receptivity for her and her LPN colleagues. In my review of the interview
transcript I was struck by how this participant gave example after example of
instances where RNs, and in some cases her unit manager, displayed not only a
lack of receptivity but also both subtle and blatant resistance to her presence and
participation on the unit's nursing care team.
One of the comments this participant made that started my consideration of
the category of receptivity regarded the impetus for the introduction and
integration of full scope LPN practice in her facility. She commented that the
move to incorporate LPNs in the select acute care units was a decision made by
management that was then imposed on the units.
...this was not something that management or staff... wanted, this was something that was implemented on them, imposed upon them so I think people need to know that because this is not what staff or managers wanted, they've had to deal with it but basically the LPN board and the powers that be decided well, we've got these LPNs that are trained, capable, cost less, more cost efficient, they just started putting them in and why are you making them upgrade to full scope and not giving them jobs, hello, you have to do it, so that's why this is happening.
51
The above quote highlights that the inclusion of full scope LPNs was a change
that was not necessarily desirable to unit staff or management and as a result
was perhaps in part to blame for the negative receptions that she and apparently
other LPNs faced. This comment that the change to include full scope LPN
practice was forced or imposed from higher up was echoed in a discussion I had
with one unit manager who told me in a separate conversation that the units were
told that they would have to choose between adding patient care aides (PCAs),
unregulated care providers, without specific assessment or nursing capabilities,
or full scope LPNs. This particular manager said that faced with this choice, they
chose LPNs because they can do more in terms of participating in patient care.
Hearing this comment from the unit manager then focused my attention on this
participant's comment. I considered how it must feel to know that you are not
necessarily wanted in an environment, but are rather being tolerated as the
lesser of two rather undesirable choices.
This participant's feeling that the unit, and in particular the RNs on the unit,
were not particularly receptive to the introduction of full scope LPNs is something
she supported with several examples, beginning with the frank statement that
some RNs simply do not want LPNs on the unit.
..some that perceive it this way are older nurses that have been there for now fifteen, twenty years and just for some reason think its always been this way, we don't need LPNs, they shouldn't be here so they just don't want them.
She mentioned that from the outset, the introduction of the LPNs on the unit
was not a wholly positive experience. She commented that there was no
52
organized introduction of the LPNs on her unit, while there was a small luncheon
in the staff room she noted that it was not well attended and did not include
actual introductions of each of the LPNs. Later, she stated that the LPNs
underwent a lengthy, 3 month orientation process that far exceeded the standard
orientation of new RNs in both length and level of detail of individual
competencies that were assessed (e.g. dressing changes); "Come on, they don't
give RNs that and new graduate RNs don't get that and we were, uh, all working
experienced LPNs".
They treated us as if we were total imbeciles, just graduates, they assessed everything we did from the way that we dressed a hang nail to the way that we signed and dotted our i's, they nit picked and nit picked and nit picked for three months.
For this participant, the orientation process and other LPNs hired was more
like an extended evaluation that showed a clear lack of respect towards the
experienced LPNs and did not recognize the more than a decade of work
experience in this facility and the nursing expertise they brought with them to the
unit. In addition, she noted and I later confirmed, that there is only one LPN on
duty on each unit for any given 12 hour shift.
So basically there's one on per shift at night, there's on per shift during the day so you're really very much alone, you don't have another person of your capacity ever on, you see them at the end of the shift when you quit.
This participant expressed feelings of being isolated, professionally, as the
only opportunity to collaborate with a peer would come at shift change or on her
days off. She also commented that she felt the LPNs were/are basically "set up
for disaster"; perhaps these feelings of professional isolation and hyper-scrutiny
contribute to this.
53
Another example of how, in this participant's view, she and the other LPNs
were not readily received on the unit is less to do with the structural aspects
mentioned above, but more so with informal interactions with RNs on the unit and
with her manager. However, communication among nurses is a thread that is
also pulled through with these examples. For example, this participant
commented early on in our interview that she has a varied range of professional
experiences in various settings and as such, felt she has the capacity to
comment on issues of patient care on her unit. However, she noted that she
rarely expresses her thoughts on the unit since the receptions those comments
receive from (some) RNs are then misconstrued.
And I think that bothers a lot of the RN's that I have a more (experience). I don't have a super specialty but I have a wide variety so I can comment on stuff that I have done in a wider scope. It doesn't make me a know it all one very subject, its just, its like a little slice of everything and they take it that way so its to a point now that I don't even share my experiences or even bother to open my mouth because its misconstrued as "oh she's blowing off again about all she's done" or you know what I mean?
In effect, she silenced herself and withheld her contribution to the nursing
team since she felt it was not being received in the manner or spirit it was being
offered.
I mentioned earlier in the previous category, an example in which this
participant gave a detailed account of an experience where she attempted to
communicate and collaborate with her buddied RN and was met with very
pointed and aggressive resistance. When she brought forward the incident to her
charge nurse, the response she received seemed hardly receptive and
apparently resulted in no supportive or other noted response whatsoever.
54
I even went to the charge nurse that day and I said, look, we're having problems here, I said we should be, um, changing our assignments here and she said well that's something that you need to work out with your RN and I said well I'm trying to work it out but she's telling me to fuck off, nothing was done, I was left to fight it out with her. So this is what I'm talking about, they set you up for disaster.
However, not all of this participant's experiences of feeling unwelcome on her
unit include such overt examples as the previous one. She recounted particular
episodes where she felt she was the target of more subtle, passive, and indirect
aggression and even shunning of her by RNs.
For example, this participant talked about how she was apparently being
excluded from conversations in the breakroom.
...well there's some bonds between people, there's some clicks, I mean I've gone into the staff room and been totally ignored for the whole forty-five minutes I've sat there even when I've tried to talk but you know what, I'm a bigger person than that.
In a caring environment which this is completely not, I think people, I think we've gone for like nine weeks and people walk right by me like I'm not even there, they don't speak to me unless I look at them and go, hello, how are you and that's always gone on and particularly too to the LPNs they do not want us there, when it comes right down to it, this is implemented on them, they see it as something that will fail eventually, sooner or later we'll be out there...
She also recounted an experience on a particular shift when she became
physically ill, was in a great deal of pain, and apparently received no expressions
of care or sympathy from the RNs on the unit that shift.
And oh, they just made me feel so guilty and so horrible, it was horrible. ...I call it schizophrenic, if you're that retarded towards a staff member like they were that night...how in hell can you turn around and be compassionate to a patient, its almost schizophrenic.
In my experience, when a nurse colleague is visibly ill, they are sent home
and as difficult as it is the rest of the team pulls together to cover the sick nurse's
55
patients until a replacement can arrive. I found this particular experience difficult
to listen to, due to the apparent lack of compassion from this participant's
colleagues. The words used by this participant to describe the incident seemed
to indicate that she was upset and even hurt by the lack of caring shown her by
her colleagues. This lack of inclusion in breakroom conversations and apparent
lack of caring behaviour towards this participant when she was physically ill on
the unit seemed to show a lack of receptivity to this participant on a more
personal even human level. The reception this participant and other LPNs on the
unit received, primarily from some RNs on the unit, seemed to take its toll; "I'm
just a single woman living in a basement suite trying to live, you know, and these
people are out for blood half the time" and "everybody is just trying to survive
this, I know some of them didn't make it".
...quite honestly everybody is just trying to survive and everybody is afraid to talk to each other that its going to be used somehow - which is why you haven't got a lot of response to your (research) ...um, yes from what I can see...
As I looked back over the numerous examples cited above, they seemed to
me to speak to a lack of receptivity on the part of some RNs and her unit
manager to both the presence of this participant and other LPNs. However,
there were a couple of instances mentioned where this participant appeared to
feel more positive about how she and the other LPNs were received; "and some,
don't get me wrong, some of the staff are wonderful, they have treated me and
others with the utmost respect but the majority don't".
In the above quote, this participant was discussing what she felt distinguished
"the good people" (e.g. some RNs) she works with on the unit.
56
But she then went on to note that even some nurses who seemed enthused at
the prospect of her arrival and that of the other LPNs being hired on the unit soon
turned unpleasant once the LPNs actually arrived; "they've worked with me,
they've worked with other people, they've seen us but then once we started
full scope it was a different story because they see you as a threat as opposed to
a co-worker".
This participant also reflected on her own perspective in terms of how she
views the workplace (i.e. the people in it) and this gave me some insight into
what attitudes or behaviours would contribute to a more receptive workplace, not
only for her and other LPNs but also in more general terms. For example, she
told me about her perspective on individuals and how she views each as a
unique whole whom she treats with respect; each person that passes through life
and each situation touches you and becomes part of you and it comes out in
some kind of way and I don't even think these people are aware of their own
behavior sometimes".
I see myself, I see all people as a whole, I don't just see them as an RN or an LPN or a doctor, these are professions, these are training things that we've taken but there's more to it than that because I know that, we judge that, I don't see that happening.
I mean I don't care, to me doctor, cleaner, I treat them all the same, they're all a vital part of health care, not going anywhere so you've got to work with them and respect them, each person has their own place in the pyramid.
In the above quotes, this participant is highlighting what in her view seem to
be important components in the workplace, namely that everyone is viewed from
a holistic perspective and is treated with respect. The notions of viewing people
57
from a holistic perspective and with respect could be viewed as two ways to
increase receptivity in the workplace, for example, to full scope LPNs such as
this participant. In the next section I will discuss the final category identified in my
analysis of this interview, appropriateness.
Appropriateness
The category stemmed from a reflection on a relatively few statement s when
compared to the other two categories. However, in my view it is important to
make a distinct category that addresses the idea of appropriateness. For the
purpose of this discussion appropriateness refers to suitability such as in the
suitability of LPN patient assignments on the unit. While certainly this category
may find some overlap with the other 2 categories I have identified thus far, in my
opinion it warrants being distinguished as the question as to whether or not the
acute care environment in appropriate for full scope LPN practice is one which I
have at various times posed to myself, and one which I have heard mentioned in
informal discussions with RN colleagues.
In the category of professionalism, this participant made several comments in
which she seemed to me to be asserting her professionalism as a nurse and her
participation on the nursing care team. However, at one point, if only briefly, she
commented on the fact that arriving at suitable, or appropriate, patient
assignment in her current work setting was challenging at times. The challenge
was related to the fact that patient turnover on her unit is quite high. Also, her
58
example of how some RNs have resisted her attempt to establish appropriate
patient assignments in fact placed her in a precarious position.
This participant commented on how, when faced with the inability to change
her patient assignment, she managed to continue to provide patient care with the
assistance of a float RN. What I did not hear mentioned was anything about the
potential for professional liability for her in working with patients who fell beyond
her scope of practice. While asserting her professionalism in the face of a
difficult patient care situation compounded by a lack of receptivity on the part of
her buddied RN and a lack of support from her unit manager, the fact remains
that she was in a sense forced to care for patients that technically fell beyond her
scope of practice (e.g. stable patients with predictable outcomes) and were
hence inappropriate for her to care for. There seems to me, therefore, to be a
potential risk to LPNs working in acute care that they may find themselves in a
situation where they are required to provide care to patients who fall beyond their
scope of practice.
Transition to Surveys
In the previous chapter I discussed my change to anonymous, mail-in surveys
as my primary means of data collection. To recap, I distributed 36 surveys in
batches to the unit managers for the units that were the original focus of my
recruiting efforts and then also to several personal work colleagues. A total of 8
completed surveys were returned over a period of 6 months for a response rate
59
of 22 percent. In the next section I outline my approach to analyzing the survey
data.
Analysis of the Surveys
My analysis involved reviewing each survey response for each question in the
survey and using colored pencils to underline what seemed to me to be key
comments and or recurrent themes. Key comments and/or recurrent themes
identified were highlighted because they were either mentioned by several
respondents or were unique to a particular respondent (e.g. only one LPN stated
that in her acute care setting the patients were too acute or potentially
inappropriate for her to work with). Over a process of a few months I reviewed
the survey responses and my underlined portions and generated categories
which reflected what I had identified in the survey responses. Following my initial
reviews of the survey data I identified 7 preliminary categories. The preliminary
categories I identified were: 1) expanded skills, 2) education/training, 3)
communication, 4) teamwork, 5) appropriateness/fit, 6) burden, 7) acceptance,
and 8) accountability/responsibility. The categories generated were often
reflected in responses to more then one question, so I proceeded to collate my
data into an excel spreadsheet which listed each category and supporting quotes
which were identified by respondent ID and the question under which the
response came. In this manner it became easier for me to visualize the
categories as well as patterns in terms of who spoke to the different categories
(i.e. LPNs and/or RNs).
60
Following further reflection on these categories coupled with additional
reviews of the study data and reorienting myself back to my research question
and the specific questions used in the surveys, I reorganized them into 3 broader
categories: defining the role, determining the impact, determining the fit of the
role. For example, from the responses to the question asking respondents what
their understanding of full scope LPN practice meant I initially identified the
categories of expanded skills, education/training and accountability/responsibility.
However, upon further reflection I noticed that comments within both of the
aforementioned categories actually stemmed from responses to questions about
understanding and meaning of full scope LPN practice. Therefore, I created the
broader more inclusive category of defining the roll (e.g. in the acute care
setting). Also, elements of the initial categories of teamwork, communication,
burden and acceptance together seemed to me to reflect how the respondents
were experiencing and perceiving the impact of the addition of the full scope LPN
role in their acute care work setting.
Each of the three categories will be discussed below, with supporting quotes
from the data provided. Also, while I approached my analysis of the survey data
as separate from that of the interview, some of the categories I identified in the
interview also appeared in the survey responses. While I did not "look" for them
in the survey responses, I did find some commonalties. Such is the case with the
category of appropriateness/fit which I discuss later in this chapter.
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Defining the Role
The category of 'defining the role' emerged as I reflected on the preliminary
categories of expanded skills, education/training and accountability/
responsibility. As mentioned in the preceding section, these 3 categories all
serve to inform a larger, more overriding category which captured nurses'
comments on the role of the full scope LPN and the defining features of that role
as seen from the perspective of both RNs and LPNs surveyed. Therefore, what
follows is my analysis of how I found both RNs and LPNs were defining the role
of the full scope LPN.
Five of the 8 survey respondents commented on the topic of the education
and preparation of full scope LPNs. Overall, the RNs and LPNs who responded
seemed to have a mixed view on LPN education (i.e. curriculum and outcomes).
One RN noted that LPNs will prepare themselves academically for their
expanded role and accompanying responsibilities; "they will work to the full scope
of their practice by taking the necessary courses and education in order o take
more responsibility for patient care".
However, most of the RN respondents commented on actual or potential
limitations of the LPNs, even if noting that LPNs will take necessary courses to
work to their full scope. Some of the RN respondents were quite critical of the
education and training of the full scope LPNs, citing critical thinking skills as
lacking or insufficient. One RN commented, "mostly I find that lack of knowledge /
education and minimal critical thinking skills in some areas puts added stress on
the partnered RN, as this directly affects trust in the partnership". Another RN
62
noted that, "with good training they will be more confident and knowledgeable
and contribute more, but may always be limited in certain "RN" situations".
Finally, one other RN noted the following:
Some LPNs are obviously stronger then others but every time I follow them and examine their care I find things that have not been fully thought through. Despite a very long conversation they still miss many of the basics as these things are not included well in their curriculum. -pharmacology; - critical thinking skills.
As the above excerpt demonstrates, while only one RN criticized the LPN
curriculum for lacking in some aspects of pharmacology, more then one RN
brought into question the LPNs' capacity for critical thinking.
The two LPNs who commented on the topic of education were clear in their
assertion that the LPN role is expanding in step with their education. As one of
these LPNs stated, "full scope LPN practice is the completed upgrading of
pharmacology, physical assessment, taking & transcribing doctors' orders, IV
therapy as well as the PN curriculum of gerontology & acute med nursing".
Another LPN respondent noted that since the introduction of her full scope role in
her workplace, however, she is finding that her education level is "constantly
being questioned". She links this with ongoing resistance from RNs in her
workplace to her being a member of the nursing team and that this contributes to
a stressful and hurtful work environment.
While education was one aspect of full scope LPN practice that was noted by
many of the respondents, both RN and LPN, expanded skill set was by far the
most commented upon by all respondents. Both RNs and LPNs cited specific
skills as defining features of what full scope LPN practice is, in their
understanding. One RN, a former LPN, commented that LPNs are, "are able to
give oral/SC/IM medications, assessments, (dressing changes), and discharge.
Under the guidance of an RN they can care for patients who are medically
stable". Another LPN noted that full scope LPNs, "...can practice full physical
assessment, med administration (basic pharmacology & geropharmacology),
taking and transcribing orders, IM/SC injections, meds by other routes except IV,
IV therapy".
Perhaps the emphasis on skills lists as defining features of full scope LPN
practice is placed because the skills lists are a tangible distinction between RN
and LPN. As I mentioned in chapter 2, in preparation for my study I spoke with an
RN coordinator of a plan to implement full scope LPN practice and she
commented that the term full scope was itself an employer generated term used
to denote the extent of utilization of LPN skills and competencies as defined by
the CLPNBC. No respondents commented on the role of their employer in
defining the term full scope. Also, the role of their employers in the
implementation of full scope LPN practice in their respective workplaces was not
commented on either.
Beyond skills and education, all respondents commented on the
accountability and responsibility associated with full scope LPN practice; as one
RN, a former LPN, noted, "LPNs are accountable/responsible for their own
practice". One of the LPN respondents commented that full scope LPN practice,
means to be able to be accountable, responsible, following the standards of
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practice and competencies as well as the code of ethics as outlined by the
College of Licensed Practical Nurses".
In addition to comments from RNs on the increase in accountability and
responsibility for LPNs working to full scope in their acute care workplace, some
RNs noted that their own level of responsibility increased when working
alongside full scope LPNs. One RN noted that she feels the RN is responsible
and therefore must care somewhat for the LPNs' patients. Another RN
commented that as a result of the scope of practice limitations for LPNs the RNs
need to carry their own patient load but also assist LPNs with certain RN tasks
(e.g. IV medication administration), thereby increasing their work load and the
number of patients they have a responsibility towards.
One LPN commented on an increase in responsibility for RNs since the
introduction of full scope LPN practice, but from her perspective she implied that
the increase was not due directly to involvement with LPN patients but rather due
to RN reluctance to assume sole responsibility for personal care of their unstable
clients. From reading the full survey of this LPN, I understand "total care" in this
case to mean total personal care (e.g. toileting, hygiene, feeding). In the opinion
of this LPN and from the perspective of some RNs, the introduction of full scope
LPN practice brings with it a new or increased level of responsibility for some
RNs with regard to performing personal care for their patients where they may
have had assistance in the past (e.g. from LPNs or care aides). The differences
in perceptions, here in the case of perceptions of increased RN responsibility
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following the introduction of full scope LPN practice will be discussed further
under the next category, defining the impact of the role.
As the LPN becomes more autonomous in the work setting it seems some
RNs may be forced to reexamine and perhaps clarify their own roles in relation to
full scope LPNs. The category of defining the role encompasses the survey
responses that comment on defining features of full scope LPN practice for both
RNs and LPNs. These defining features of full scope LPN practice include:
education (i.e. to meet full range of entry-level competencies as outlined by the
CLPNBC), an expanded skill set and scope, and increased level of accountability
and responsibility.
Overall, LPNs and RNs were able to articulate a clear understanding of what
constitutes full scope LPN practice and often used specific skills as indicators or
defining features. Some RNs used notions of limitations and even cited specific,
perceived deficiencies (e.g. lack of knowledge and critical thinking skills) and/or
increase in RN responsibilities as defining features of the full scope LPN role.
However, generally there was consensus on what defines the role of the full
scope LPN (e.g. accountable and responsible for own patient load of stable
patients with predictable outcomes with the ability to perform specific nursing
interventions consistent with their scope as outlined by the CLPNBC). Thus it is
logical to conclude that a major point of agreement between the two is what
constitutes full scope LPN practice. However, there seems to be some
difference in opinion between some RNs and LPNs as to the extent of knowledge
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or educational preparation of full scope LPNs and their ability to apply this
knowledge critically in practice; I elaborate on this notion in the next chapter.
Determining the Impact of the Role
This category emerged upon subsequent review of my preliminary categories
that seemed to capture respondents' perspective regarding the impact of
including the full scope LPN role in their acute care setting. The preliminary
categories that informed this broader category include: burden, teamwork and
communication. In addition, I also found upon subsequent reviews of the survey
data, that some LPN responses fell outside these preliminary categories. For
example, statements of personal and professional satisfaction did not readily 'fit'
into the aforementioned categories of burden and teamwork. Therefore, creating
the category determining the impact allowed me the freedom to include more
descriptive statements that highlighted the broad and varied impact of full scope
LPN practice on nurses. Responses from nurses who responded to my survey
were varied, both among RN and LPN respondents and between them. What
follows is my description of the impact of full scope LPN practice on the survey
respondents. To facilitate my discussion of this category, I have divided my
discussion of impact into 3 subcategories, namely: burden, teamwork and
personal impact.
Burden. Of the RNs, 4 of 5 commented on the impact of full scope LPNs in
the nursing skill mix on them in terms of additional burden. This sense of burden
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also became apparent while I was examining the previous category and noted
that some RNs were defining full scope LPN practice, in part, by the increase in
responsibility for them. This increase in responsibility was, for some RNs, felt in
terms of taking on heavier patients (i.e. greater acuity and/or complexity) and
taking on "RN" tasks for LPN assigned patients.
Mostly I find that lack of knowledge/education and minimal critical thinking skills in some areas puts added stress on the partnered RN...the LPNs are having a lot of trouble coping (time management wise) and therefore aren't much help to the RN buddied with them who has 3 much heavier pt's then one normally would if they weren't "teamed up" with an LPN.
Another RN commented on the impact of including full scope LPNs on her unit
and related loss of a full time care aide position.
With the addition of full scope LPNs to our floor, we have lost a floating full-time care aid who helped with wastes, transfers, mobilizing and many other 2-person, time-consuming jobs. Now all the primary nurses do everything themselves or need to find another qualified RN or LPN who also have their own assignment, to help with heavy work, of which there is a lot. The LPN works in one modified team assignment with an RN. Each takes a pt. load, but the LPNs pts may have "RN tasks" for the RN in that team. Also, the LPN can't do "RN tasks" for anyone else on the floor. So it sometimes means they don't circulate their help when they have time to spare. Their role is also newer to them, so I feel this is partly the reason as they are filling up their day with their own patients and not looking beyond."; "Overall, I feel that the LPNs have brought some great + positive, experiences to the floor with their own expertise, but that the overall workload has changed in a negative way for the RN's on the floor. "; "We still have care aids come in for the extra difficult days, but we have had a lot of back injuries and sick time lately in my perception, which I partly attribute to the 4s workload since we started using FSLPNs and got rid of our full-time care aids. I also think it is not saving any money for this reason.
As mentioned in my discussion of the category, defining the role, it was not
only RNs who acknowledged an increase in RN responsibility as a result of the
introduction of full scope LPN practice. One LPN commented that in her
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experience, "RN's are reluctant to take more responsibility regarding "total pt
care" of unstable client". She went on to add that the introduction of full scope
LPN practice into the acute care setting is resulting in a shift in responsibilities for
patient care for both RNs and LPNs; "Many RNs have worked their careers
without doing any pt care. The pts they are now expected to care for & assess
were the ones previously done by the LPNs. They only dealt with the meds and
IVs". What this comment seemed to indicate to me is that this LPN is
acknowledging the impact of full scope LPN practice for RNs (e.g. resulting in an
increase in responsibilities formerly delegated to LPNs and now being added
back to the role of some RNs).
Another LPN acknowledged the sentiment among some RNs that their
workload has increased since the introduction of full scope LPNs and also
commented that assignments are divided and, depending on who she is working
with, she is able to diwy up tasks to help balance the workloads.
e.g. RN hangs my IV bag ofKCL I will do their ins/outs or something that LPN is not able to do because (it is) not within their scope... If the pt assignment is 7 - LPN takes on the 4 - RN 3 pts - because RN has to do LPN's duties (Example given: RN has to hang TPN)
Some survey respondents, however, did not comment on the notion of burden
for either RN or LPN but rather focused on the idea of teamwork between RNs
and LPNs. Perhaps the notion of burden and increased workload for some RNs
was noted by some respondents and not others due to differences unit
organization or leadership. For example, perhaps some RN respondents have
experience working in environments where they have assumed total care of their
patients and thus there is no impact in this area on them since the introduction of
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full scope LPNs. Or perhaps, the introduction of full scope LPNs on some units
was implemented in such a way or handled by the nurses in such a way as to
ensure responsibilities were shared and therefore a notable burden was not
perceived.
Teamwork. In my review of the survey responses to questions regarding
experiences working with or as a full scope LPN, one of the recurrent topics I
noticed was that of teamwork. Some nurses commented that RN/full scope LPNs
were able to work effectively as a team. Some nurses noted some difficulties
pertaining to teamwork among RNs and full scope LPNs. One RN, a former LPN,
commented on specific characteristics of the LPN that facilitated teamwork.
As a current RN and a previous LPN full scope, I think that both professions can work together in harmony as long as it is clear what that scope of LPNs is. As well as the LPN vocalizes their limitations and seeks assistance when they need help. ... The LPNs I have worked with are knowledgeable about their limits, caring, very independent and strong in communication skills. This makes working in RN/LPN mix very easy.
As I mentioned, however, some respondents commented on problems with
teamwork. Problems with teamwork that were noted differed between RNs and
LPNs. For example, one RN observed that the LPNs ability to contribute to the
team is limited by the fact that relative newness of the full scope role in the acute
setting, the high acuity of the patients, and the limitations of their scope of
practice results in the LPNs tending to focus on their own assignments and being
limited in the contribution they can make towards the RN's patients.
The LPN works in one modified team assignment with an RN. Each takes a pt. load, but the LPN's pt's may have "RN tasks" for the RN in that team. Also, the LPN can't do "RN tasks" for anyone else on the floor. So it
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sometimes means they don't circulate their help when they have time to spare. Their role is also newer to them, so I feel this is partly the reason as they are filling up their day with their own patients and not looking beyond.
Yet another RN noted that one LPN had repeated personality conflicts with
RNs that stemmed, in her view, from resentment for the presence and potential
involvement of RNs with her patients. This RN felt that the LPN was offended
when others pointed out she was not an RN and would require assistance with
some things; "she would get verbal and defensive when it was pointed out she
was an "LPN" not an "RN", and she took offense to any suggestion that she
needed to get help from an RN".
However 3 of the LPN respondents commented on difficulties with teamwork
and attributed them to the RNs. Three reasons for difficulties with teamwork were
noted by LPN respondents. First, one LPN cited an inconsistent desire on the
part of RNs to work in a team with LPNs; "depending on who I'm working with,
some RN's are able or enjoy as I do working in a team environment". Second, on
LPN commented on RN resistance to the presence of the full scope LPNs; "I as
an LPN (am) meeting resistance, noncompliance as being respected as part of
the team on most shifts. I find this extremely stressful & hurtful". Third, one LPN
noted a lack of focus on collaborative practice (e.g. with LPNs) in RN education
programs; "RNs that are good are moving to other areas or retiring. The quality of
the med/surg RN coming in is not the same standard. They are not taught to be
team players in many areas".
Overall, in reading the survey responses I got the sense that while an
RN/LPN skill mix could be effective, the onus is largely placed on the LPN to
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make it work. For example, if the LPN is clear on their scope and limitation and is
able to articulate them among other things, working in an RN/LPN skill mix. One
LPN commented that when she first was introduced to her unit she found it
stressful due in part to the higher acuity of patients but also due in part to the
hesitance of RNs in working with LPNs; "the RNs were very reluctant on having
LPNs on the floor, but as time progressed and the LPNs were able to prove
themselves the RNs (some of them) were able to accept it."
The idea that, initially at least, the LPNs faced some hesitance, resistance or
even mistrust from some RNs was also noted by an RN respondent who
originally thought there would be an increase in patient safety issues arising from
the introduction of full scope LPNs (i.e. since patients often present with multiple
co-morbidities). However, this RN then went on to comment that she felt more
comfortable with the idea of full scope LPN practice, "after working with the LPNs
for awhile".
Overall, in my review of the survey responses, I found that the introduction of
the full scope LPN into the acute care setting impacts RNs and LPNs but in
different ways. RNs commented on an increase burden of responsibility and
workload. LPNs commented on the need to prove themselves, in a sense facing
a burden to prove their role in the team. Another aspect of the impact of the
introduction of full scope LPN practice is felt in terms of teamwork between RNs
and LPN. While some respondents commented that they have worked effectively
in a RN./LPN skill mix, there is clearly room for improvement. Some RNs note the
limitations of LPN practice and a perceived imbalance of patient care delivery
72
that leaves some RNs to face a heavier, more acute patient load with less
available assistance. While one LPN acknowledged that some RNs feel their
workload is increased since the introduction of LPNs, other LPNs commented
that they offer to help rebalance the workload as best they can but that it
depends on the RN they work with. The willingness, or lack thereof, of nurses to
work together in team oriented manner was something addressed by RN and
LPN respondents and is, in my view, a significant factor when considering the
notion of teamwork. If members of a team are not willing or able to work together
as a team, then the function of that team and their common goal, in this case
patient care, must undoubtedly suffer.
One RN gave an example of an LPN who resisted collaboration with RNs.
One LPN noted that some newer RNs are not educated to have a team
orientation, at least from her perspective as an LPN. As quoted earlier, another
LPN commented on how the resistance she experienced from some RNs to her
presence on the team caused her to feel stressed and hurt. In the next section I
will discuss the personal impact on both RNs and LPNs of introducing full scope
LPN practice into acute care.
Personal impact. In my review of the survey responses I became particularly
interested in the personal impact of full scope LPN practice on the RNs and
LPNs, their feelings surrounding the introduction of the full scope LPN role.
While some nurses, both RN and LPN, expressed having positive experiences
overall working with a RN/LPN skill mix, each group highlighted unique features
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of this positive experience. Several LPNs expressed feeling happy or satisfied
with finally being able to work to the fullness of their competencies and
capabilities. For example on LPN noted that she was now, "happy to be able to
use all skills. More fulfilled to be able to learn more and apply it to practice".
One LPN cited feeling better received as a nurse now that she worked to full
scope in the acute care setting, "I feel more accepted as a nurse for making
contributions that I am capable of. Yet another LPN expressed satisfaction in
being able to provide continuity of care for her patients.
...rewarding for me because I have worked at other facilities in this capacity & loved it. I am able to practice what I learn. To be able to nurse from the beginning to the end is more satisfying in the sense that you are more in complete contact of your assignment & patients.
However, not all feelings expressed by LPN respondents were positive. Two
LPNs commented on feeling stress as a result of RN resistance to their presence
on their unit(s) as well as high patient acuity. Yes another LPN expressed feeling
of annoyance and frustration; "annoyance that it has taken 20 years to accept
this role, frustration that there is blurring of LPN/RCA duties and role
expectations".
This LPN's feelings seemed not so much a result of specific experiences with
RNs on her unit(s), but rather with what seems to be more broad reaching,
systemic issues, such as others' perceptions of role confusion between LPNs
and care aids, and the length of time it has taken for the full scope LPN role in
acute care to have come to fruition. These mixed feelings regarding the full
scope LPN role in acute care were not limited to LPNs.
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For example, several RN respondents cited positive experiences, overall, in
working with full scope LPNs. Others expressed feeling stressed and perceiving
an increase in RN injuries and sick time since the introduction of full scope LPNs
and increase in workload for RNs.
Overall, I feel that the LPNs have brought some great +positive experiences to the floor with their own expertise, but that the overall workload has changed in a negative way for the RNs on the floor. ... We have had a lot of back injuries and sick time lately in my perception, which I partly attribute to the increased workload.
One RN observed that working with LPNs who, in her view, lack knowledge
and critical thinking skills is a source of stress and also impacts the RN's trust of
the LPN.
My experience has been mostly positive. Working with a full scope LPN can be challenging if the person I'm working with is new or a float LPN that I don't know. Blending styles of nursing and personalities can be challenging. Sometimes trust is an issue - I have good working relationships with the regular LPNs on our ward at this time.
Despite feeling stress, perhaps some mistrust, and a sense of burden as
mentioned in a previous sections, some RNs commented on a bigger picture,
beyond their individual experiences on their unit(s). In other words, they feel that
a period of adjustment, working in the new skill mix, will ultimately facilitate their
adaptation to the changes in skill mix. Also, one RN even expressed empathy for
the LPNs as she reflected on the impact on both RNs and the LPNs. This RN
acknowledged that the increase demands of their expanded scope and the acute
setting could be a source of stress for the LPNs.
A bit of a difficult transition, mostly due to the acuity of patients. ...lack of knowledge/education and minimal critical thinking skills in some areas puts added stress on the partnered RN, as this directly affects trust in the
relationship. ... The patients are demanding given the complexity of their illnesses, and I can understand how stressful that would be.
Overall, I found that the respondents provided me with many insights into how
the introduction of the role impacted them in terms of their workload (e.g.
burden), work relationships (e.g. teamwork) and on a more personal level as well
(e.g. increased job satisfaction and stress). In addition to commenting on the
impact of the full scope LPN role in their workplace and on them personally, the
nurses who responded to my survey also commented on the notion of the
appropriateness of the full scope LPN role.
Determining the fit of the role
The third and final category I identified from my reviews of the survey data
includes responses regarding the perceived fit of the full scope LPN role in acute
care in the present, but also in some cases in the future. For the purpose of the
discussion of the survey results, fit refers to the suitability of the full scope LPN
role in the acute care setting. All respondents commented to varying degrees on
this topic, however overall the RN respondents appeared to have more to say
compared with the LPN respondents.
Some of the LPN respondents, as mentioned in the previous section,
mentioned feeling more satisfied with being able to care more fully for their
patients. While not explicitly stating it, in my view this implied a perception that
these nurses felt their role was both appropriate and a fit for the acute
environments where they worked. Only one LPN commented, and then in only a
few words, that she did not feel her role was appropriate in the acute
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environment, "patients aren't appropriate for LPNs (too acute)". This LPN was
unique with this comment on a mismatch between role and patient environment.
While a couple of LPN respondents commented on some uncertainty
regarding the fit or appropriateness of the full scope LPN role in the acute care
setting, their comments were directed to the system in which they work. For
example, one noted that the future of the LPN role in the acute setting is
uncertain because there are few LPNs working in her work setting at present.
Therefore, in my view, perhaps this LPN was uncertain about the future and fit of
the full scope role largely in part because she did not have enough exposure to
seeing the role implemented in her workplace.
Another LPN commented on animosity from RNs directed at the full scope
LPNs and attributed this to a poorly implemented introduction of the role initially.
I think the introduction of the LPNs at full scope was poorly done. It has caused a lot of animosity between nursing groups. I think the public need to be more educated about LPNs and their role in the health care system.
This LPN also noted that public education of the LPN role is necessary. From
my understanding of what this LPN stated, the perception of appropriateness of
the full scope LPN role is largely in the eye of the beholder. In other words, how
the role is introduced and how others understand the role of the full scope LPN
could play a significant role in both the determination and perceptions of
appropriateness or fit of the role.
Finally, another LPN noted that the full scope LPN is a "new level as the
replacement of the diploma nurse" and that in the face of an ever increasing RN
nursing shortage the LPN can help alleviate the shortage by applying their
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capabilities where appropriate. This LPN noted that the LPN role is appropriate in
the acute care environment, with patients who fall within their scope (i.e. patients
with predictable outcomes); "even in acute setting, (which is where I work) there
are always this cross section".
While all but one LPN appeared to feel that their role was appropriate in their
respective acute care settings, several RNs did not feel the same. In fact a
couple of RNs stated quite clearly that in their view the full scope LPN role was
not appropriate in their work setting(s). These nurses cited high patient acuity
and unpredictability as key reasons why the full scope LPN role did not fit.
Personally, I don't think (full scope) LPNs are appropriate on our ward (vascular). The pt's have multi-faceted & complex issues that are outside their limited ability to critically think. On this ward a full scope "workload" role would be more appropriate.
I believe it is inappropriate to have (full scope) LPN where I currently work. In a team setting as an assistant would be fine but as an independent nurse, it is not safe. We do not have a "stable population with predictable outcomes". We have very sick patients with multiple co-morbidities that often never become stable. It is not uncommon for our pts to suffer a CVA or Ml or PE even day of discharge. I have seen LPNs both under and over react to situations, I have not yet seen the critical thinking skills required to work in our setting.
From the above quotes, it is clear that these RNs do not feel that the full
scope LPN role, perhaps as it is currently being utilized, is appropriate to their
work setting. In addition, and in response to the question regarding views for the
future of the full scope LPN in acute care, one RN had a strong reaction.
Frightening. Based on a review by D&T done at our place we should be (approx) 23 LPN + 77% RN. Presently it is 10% 90% and it is already scary. The RNs watch + help and often have to change assignments through the shift. Increasing this ration I believe would result in deleterious events for patients.
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However, this same RN later went on to comment that she believes there is a
role for the LPN in acute care but as a "team worker with an RN". She stated that
LPNs are often great patient advocates and would be perhaps better suited to
work in post-acute, long term and transitional care settings where they would
practice with greater independence with a more stable patient population.
Another RN reinforced this view of the importance of context in determining
appropriateness of the full scope LPN role. Other RN respondents were more
receptive to the incorporation of full scope LPNs in acute care, as long as the
context (e.g. patient population) is appropriate for their scope of practice. As one
RN noted, "LPNs in acute care will be moved to areas where they contribute the
most" and that "with good training they will be more confident and knowledgeable
and contribute more, but may always be limited in certain RN situations".
One final factor that may play a role in how the appropriateness of the full
scope LPN role in the acute care setting is determined is the personal
characteristics of the LPN. In the view of some RNs: a) if the LPN is able to look
beyond his/her own assignment and make an additional contribution to other
patients on the team; b) if the LPN is strong in communication skills and well able
to articulate their role; c) if the LPNs are knowledgeable (e.g. pharmacology); and
d) if the LPN consistently asks for RN assistance when necessary, then the
RN/full scope LPN skill mix in acute care can work. In the view then of some
RNs, it may well be up to the LPNs to prove themselves in these ways in order to
demonstrate appropriateness of their role in acute care. This is consistent with
some LPN comments referring to how they feel the need to prove themselves.
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The Interview and the Surveys
As I mentioned in the previous chapter, my analysis of the sole interview and
9 completed surveys were approached separately. My process of analysis itself
(e.g. viewing and reviewing the data, reflecting back on my research question
and questions asked, and identifying and then refining categories) was applied to
both sets of data, individually. While I did not seek out differences and similarities
between the interview and survey data during the analysis itself, once each
analysis was completed I reflected back on the results of both to see if there
were any points of comparison.
What I found in the interview was an overwhelming focus on challenges this
LPN faced to practicing at full scope on her acute care unit. She expressed
meeting resistance to her presence, in several forms, such as: having her
professional competencies and capabilities challenged, and perceiving a lack of
receptivity to her inclusion on the unit and to her contribution as a nurse. Some
LPN survey respondents also expressed feeling that the introduction of their role
in their acute care setting(s) has met with resistance from some RNs along
similar lines to what the interview participant stated. In my analysis I also noted
resistance from RNs to the introduction and/or ongoing presence of full scope
LPNs in their respective acute care settings. This RN resistance was evident in
comments such as those in which RNs noted that after some time working
together they feel more comfortable with the LPNs and those where RNs stated
frankly that LPNs are not appropriate in their setting.
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Some RN survey respondents commented that the full scope LPN role is and
can be effective in the acute care setting as long as patient assignments are
appropriate and suggested a workload or less independent role. The LPN
interviewed and LPN survey respondents did not comment on other possible way
of utilizing LPNs to their full scope but rather asserted their capabilities to provide
full care for patients (e.g. within their scope of practice) in acute care settings,
save for select RN tasks.
Overall, in my review of the data and final categories I am left with the sense
that that both LPNs and RNs have mixed reactions to the introduction of the full
scope LPN role in acute care. There are clearly challenges for both groups as
they adjust to the changes. Some RNs are not receptive to the introduction of the
full scope LPN role on their respective units, but these RNs were in a minority.
Overall, the nurses appear to be facing the task of adjusting to change and
determining how it is working/will work and what it means for them. Most survey
respondents as well as the LPN interviewed see the role of the full scope LPN in
acute care as viable and timely. How this role is introduced and supported once
established is something for further consideration perhaps. The LPN interviewed
observed that the manner in which the LPNs were introduced on her unit and an
ongoing perception of lack of support for their presence from her unit manager
both had a negative impact on her experience. The notions that the manner in
which the role is introduced and the attitudes of others both have an impact on
the full scope LPN was supported by some of the LPN survey respondents as
well. This would suggest to me that an important factor in nurses' experiences
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with full scope LPN practice could be working to establish and ensure a receptive
work environment which is appropriate to the LPN role. In the next chapter I will
discuss this further as well as propose some suggestions for possible future
research in this area and possible implications for nursing education regarding
the LPN role in acute care.
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CHAPTER V
Discussion
In undertaking my qualitative description study I sought to gain an
understanding of how nurses, both RNs and full scope LPNs, are experiencing
and perceiving working in a RN/LPN skill mix in the acute care setting. Currently
there is little formal literature soliciting the experiences of RNs and LPNs who are
living the change in skill mix in recent years to include full scope LPN practice. As
an RN and a practical nurse educator in the acute care semester of an
established PN educational program in the Lower Mainland I have been involved
in the preparation of LPNs for full scope practice in acute care. In my
experience, I have often been asked questions by RNs about the meaning of full
scope LPN practice in the acute care setting. I have also been privy to
conversations among some LPNs who viewed little distinction between their
practice and that of RNs (i.e. ability to administer IV meds being cited as a main
distinction). The enhanced range of entry-level competencies included in the full
scope of practice for BC LPNs in 2000 is continuing to expand and educators are
attempting to keep in step with these changes to entry-level competencies. In
my work as an LPN educator, I helped facilitate my students' socialization into
RN/LPN skill mixes in various acute care settings where full scope LPN practice
was not yet fully implemented. During this time I became increasingly curious
about how RNs and LPNs would experience working in an RN/LPN skill mix in
the acute care setting with LPNs practicing at full scope. Therefore, I undertook
this study with the hopes of gaining a more informed understanding of the
8 3
experiences of RNs and LPNs working with or as full scope LPNs in the acute
care setting.
In this chapter I will discuss the findings from my study with my conclusions. I
then explore some related work and go on to discuss implications from my
findings that help to inform and/or lend support to strategies for nursing practice,
nursing education, nursing policy and future nursing research.
Research Conclusions
As I described in earlier chapters I interviewed one LPN and received short-
answer mail-in surveys from 8 nurses (3 LPN and 5 RN). I used conventional
content analysis as outlined by Hsieh and Shannon (2005) to guide my analysis
of the interview and survey data. From my analysis of the single interview I
identified 3 categories: a) professionalism, b) receptivity and c) appropriateness.
Professionalism included participant comments that seemed to assert her own
professional identity and role on the team as well as comments regarding
perceived challenges to her professionalism (i.e. from some RNs and her
manager). Receptivity captured the notion of how this LPN believed she and her
LPN colleagues were received on her unit (e.g. by RNs and management). Also
included in this category were comments that suggested factors that could
positively influence how LPNs are received into a RN/LPN skill mix in acute care.
Appropriateness was developed to include ideas around suitability of the acute
care setting for the LPN (e.g. patient assignments). Seen together, my analysis
of the interview with the LPN participant yielded a picture of a nurse who felt
84
competent and proud to be an LPN yet in practice faced many challenges and
barriers to working and being part of the RN/LPN team in her acute setting.
Feelings of having her professionalism and professional identity challenged and
feeling poorly received personally and professionally seemed to dominate in her
interview. The challenges she expressed did coincide with some of the barriers to
increased LPN utilization identified by Greenlaw (2003), namely role conflict, lack
of support and acceptance and possible "turf" protection (e.g. RNs protecting
their "turf' (p. 13).
However, this participant did discuss some factors that she seemed to feel
could make a positive impact on her work setting and experience. Such factors
as ensuring all staff members adopt a holistic, open-minded approach towards
one another (e.g. seeing past the job titles and recognizing the humanness of
each person) and treat one another with respect (e.g. RNs being more respectful
towards LPNs).
Following the sole interview, and faced with the realization that I was unable
to recruit more individuals to face to face interviews, I distributed 36 short-answer
surveys to unit managers from the selected units targeted by my initial
recruitment efforts and also to 3 personal work colleagues. Eight of the 36
surveys were returned completed and subsequently analyzed using conventional
content analysis.
From my analysis of the surveys I identified 3 categories, not wholly different
from those identified in the analysis of the single interview. The 3 categories I
identified from the survey data include: a) defining the role, b) determining the
85
impact and c) determining the fit of the role. Defining the role was developed
from survey responses from RNs and LPNs that seemed to demonstrate their
respective efforts at defining the role of the full scope LPN in the acute care
setting. There was a notable emphasis on particular skills the full scope LPN is
sanctioned to perform. Respondents also commented on the additional
educational preparation of full scope LPNs. However, the extent of this
preparation was questioned by some RN respondents (e.g. extent of education in
pharmacology and critical thinking). Increases in LPN accountability,
responsibility and accompanying autonomy in practice were also commented on
as features of full scope LPN practice. Some RNs defined full scope LPN
practice as it related to their own practice and some cited an increase in their
own workload as a defining feature. For example, some RNs commented that full
scope LPN practice meant they now had their own patient assignment and in
addition were required to perform RN skills for some LPN patients such as IV
medication administration. Finally, some nurses stressed the collaborative aspect
of full scope LPN practice.
Determining the impact encompassed RN and LPN comments regarding how
full scope LPN practice impacted them and their work experience. More
specifically, some RNs felt burdened by an increase workload of providing care
to patients with unpredictable and complex health challenges while also aiding
LPNs in caring for their patients with tasks that fall outside the LPN full scope of
practice. Overall, LPNs expressed a greater sense of satisfaction at being
empowered to work to the fullness of their scope. However, one LPN noted that
patient acuity in her acute setting was too high. Some RNs noted that they have
developed good working relationships with the LPNs on their team and that the
teamwork is effective. Other RNs and some LPNs saw room for improvement in
the area of teamwork as perhaps the introduction of the full scope LPN role can
perhaps initially appear to polarize nurses as nurses focus on managing their
own assignments (e.g. LPNs focusing too much on their patients and RNs being
reluctant at times to collaborate with LPNs). Certain LPN characteristics (e.g.
good communication skills and knowledge of own limitations) were cited that,
from the perspective of some RNs, enhanced the RN/LPN working relationship.
From the perspective of some LPNs, RN reluctance and critiquing of LPNs was a
barrier to teamwork and was also a source of stress and even hurt feelings.
Overall, there are some definite positive impacts of the full scope LPN role on
both RNs and LPNs yet there remains room for improvement (e.g. in teamwork,
with some LPNs stressing the attitude of some RNs as a barrier to teamwork.
Finally the final category, determining the fit of the role encompassed
comments made by RNs and LPNs regarding the appropriateness of the full
scope LPN role in their acute care setting. This category appeared to be
dominated by the RN respondents, some of whom felt the inclusion of full scope
LPN practice was inappropriate on their units. Other RNs suggested that the
onus of LPN fit in their acute setting lay with the LPNs themselves to in effect
prove their fit on the team. Some LPNs felt that their fit on their units improved
once they had an opportunity to prove themselves (e.g. to the RNs) and when
RNs were less resistant to their presence.
87
Related Work
There is limited available literature pertaining to full scope LPN practice in
acute care. However, the Vancouver Island Health Authority (VIHA) began
implementing a shift to implement full scope LPN practice in various facilities in
2002 with projections of 63% of LPNs working at full scope in acute care and
rehab facilities by May, 2003 (Stein, 2003). They used this implementation
project as an opportunity to conduct research into the impact and effectiveness of
their full scope LPN implementation project. Phase one involved education aimed
at broadening the range of functions for LPNs, towards full scope practice. In
phase 2, research was conducted to solicit nurses' perceptions of their work
environments and the process of implementing full scope LPN practice with 6
themes identified. Twenty-four nurses (11 LPNs and 13 RNs) participated in the
second phase evaluation, all considered senior level nurses from various sites
with 20 or more years of practice experience and selected by their managers.
While it is not clear what proportion of nurses worked in acute care settings,
some of the findings from this study are reflected in findings from my study. For
example, one of the six themes entitled "double edged sword" refers to the mixed
responses of both RNs and LPNs. On one hand, nurses reported factors that
resulted increased job satisfaction (e.g. RNs working as mentors and LPNs
assuming more control and responsibility for patient care). However, on the other
hand, both groups of nurses also reported factors that contributed to a negative
effect on job satisfaction (e.g. increased job stress).
88
In my findings from the survey analysis, under the category of determining the
impact, RNs and LPNs commented on the positive and negative impact of full
scope LPN practice. Some LPNs reported an increase in job satisfaction relating
to being able to work to full scope and provide greater continuity of care. Unlike
in the VIHA study, no nurses I surveyed commented on the mentoring role of
RNs. However, respondents from both groups of nurses commented to varying
degrees on factors which increase job stress such as increase in perceived
workload, high patient acuity and inconsistent teamwork.
Not all themes identified in the VIHA project evaluation were reflected in my
findings. For example, one theme entitled gray area referred to confusion around
the role of the LPN and how to best organize patient assignments and care. The
nurses who responded to my survey seemed to be able to clearly articulate the
role of the LPN, although often relying on skills lists for differentiation. Perhaps if I
had surveyed more nurses and/or included a question that specifically asked
about gray areas with regard to full scope LPN practice I might have a different
result. Or, perhaps in 2005 nurses are more familiar with full scope LPN practice
and what it means. Five of the 9 survey respondents had attended joint
CRNBC/CLPNBC RN/LPN workshops at different times in the years leading up
to my study and there was no recognizable difference in reported understandings
of full scope LPN practice between respondents who attended the workshops
and those that did not. Perhaps information regarding the LPN role was obtained
by nurses who did not attend the workshops through articles in Nursing BC,
publications from the CRNBC, unit managers, colleagues, or other sources.
89
Implications
Based on my findings from the study I have identified some implications from
my study and strategies aimed at nursing practice, education, and research. As I
considered the following implications I remained cognizant of the fact that the
scale of my study was small and future research efforts on the issue of full scope
LPN practice in acute care settings might be useful in strengthening my
implications and proposed strategies.
Implications for Nursing Practice
The central importance of fostering effective teamwork in RN/LPN skill
mixes emerged as an important implication from this study. One way to begin
that process might be to put in place systematic plans detailing approaches to
facilitating effective communication between RNs and LPNs. Such strategies
might benefit both groups of nurses and the nursing team as a whole. From the
findings of my study, I have identified several directions for improving
communication and teamwork among RNs and LPNs; in effect improving nursing
practice from the perspective of the environment in which RNs and full scope
LPNs practice and the working relationships among them. In my analysis I
identified a number of comments made by participants that highlighted
challenges to RN/LPN practice in their acute care settings. For example, the sole
interviewee spoke of a perceived lack of caring and respect (e.g. demonstrated
by some RNs towards herself and other LPNs) and also impaired communication
between RNs and LPNs (e.g. LPN input in patient care discussions not
90
welcomed). Some survey respondents commented teamwork is not always
present or effective between LPNs and RNs. However, other respondents noted
that after time spent working together, they felt that they worked more effectively
together and relationships were strengthened. Finally, one RN, a former LPN
noted that when LPNs are able to clearly articulate their role and communicate
effectively with RNs, teamwork is improved.
Following my review of my analysis, I identified 3 potential strategies for
improving nursing practice by fostering teamwork (e.g. via improving
communication and collaboration) between RNs and LPNs. In my view, these
strategies will contribute to improvements in the practice environment of RNs and
LPNs as well as the working relationships among them. The first strategy is one
which I observed in action on several acute care units at Richmond Hospital that
have recently implemented full scope LPN practice. The second strategy stems
from a comment from the LPN participant I interviewed who noted that there
were no regular unit meetings to discuss patient and professional issues and how
she felt communication among unit nurses had much room for improvement. The
third and final strategy I present offers a potential means to foster communication
and collaborative practice among RNs and LPNs while also providing role
modeling examples that could be used by nurses in various units.
First, in order to facilitate and promote communication between RNs and
LPNs working on acute care units, regular scheduled team meetings between
these nurses (e.g. buddied RNs and LPNs) could occur each shift. In my recent
experience as an LPN educator on two units at Richmond hospital I noted a
91
policy that was adopted at the time full scope LPN practice was implemented.
Midway through each shift where LPNs and RNs worked together, LPN/RN pairs
are required to meet and discuss their patients for a minimum of 15 minutes.
Second, in addition to mid-shift meetings between RN and LPN buddies,
regular unit team meetings could be conducted (e.g. every month or two
months). Unit meetings, facilitated by a consistent person (e.g. clinical nurse
leader) who openly supports and encourages the RN/LPN skill mix, in which
issues of patient care, concerns in practice, and also successes in teamwork are
openly discussed could result in enhanced communication and willingness to
view themselves as part of a team rather then two distinct groups of practitioners
working alongside one another.
Third, in order to foster and strengthen collaborative practice among RNs and
LPNs I suggest the CLPNBC and CRNBC produce joint publications, perhaps
monthly, that promote examples of effective RN/LPN teamwork and collaborative
practice. The colleges, in collaboration with employers, could put out an ongoing
call for submissions of practice examples that highlight the work of LPNs and
RNs. Each month, a single example could be selected and published and the unit
where the example stemmed from could be rewarded with pens or pins that
stated something like "Nurses Working Together". Perhaps at the end of the year
one unit could be selected for a profile/write-up highlighting how their RNs and
LPNs are working effectively together and that unit could receive a lunch. By
combining a small incentive program with a means to highlight effective practice
and RN/LPN teamwork, nurses at the bedside might be motivated to seek out
positive examples of teamwork and collaborative practice and also learn from the
experiences of nurses on other units (e.g. examples serve to model effective
behaviours/practice). These publications might also be useful in nursing
education programs (RN and LPN) in courses that deal with professional practice
issues and aid students by providing models for effective teamwork.
The aforementioned strategies are presented as potential means of nurturing
supportive, team oriented work environments for RNs and LPNs. In the next
section I discuss some implications for nursing education with some strategies
for promoting effective practice among RNs and LPNs, with a focus on the
education of student nurses.
Implications for Nursing Education
As mentioned in chapter 4 and the discussion of findings in the previous
section, the importance of role clarity, communication, willingness to collaborate
and ability to function in a team environment are notable. Findings from this
study lend support to initiatives that aim to foster all of the aforementioned in
nurses, in particular in student nurses. For example, Villenueve and MacDonald,
(2006) propose that en effective strategy for approaching nursing education in
the future in Canada would involve a unified, laddered program structure where
all LPNs and RNs would share their initial education (e.g. the length of the LPN
program). A shared educational experience would contribute, it is hoped, to
enhanced collaborative practice because there would be a foundation of
collaboration and understanding on which to base working relationships in
93
practice. This move towards a collaborative educational model has already been
adopted by Vancouver Community College with the upcoming introduction of a
BSN stream in their nursing program in 2008.
Implications for Nursing Policy
As mentioned in the discussion of findings in the previous section, the central
importance of fostering effective teamwork in RN/LPN skill mixes emerged as an
important implication from this study. Findings from my study lend support to two
current policy initiatives in BC aimed at fostering collaborative practice. The first
initiative is the Collaborative Nursing Practice initiative aimed at clarifying and
enhancing collaborative nursing practice among RNs, Registered Psychiatric
Nurses (RPNs), and LPNs in BC (Greenlaw, 2006). A central concept in
collaborative nursing practice is increased understanding among nurses of their
respective roles (e.g. similarities and differences) leads to increased respect and
that respect is integral to effective collaboration. In my findings, some LPNs felt a
lack of respect from some RNs and a need to prove themselves. The
Collaborative Nursing Practice Steering Committee, a subcommittee formed from
the Nursing Directorate of BC, produced a resource tool aimed at managers and
educators which offered specific information and strategies for promoting
communication, understanding, and teamwork among nurses. For example, the
resource tool presents an exercise, using simulated patient cases, aimed at
helping nurses identify appropriate RN and LPN patient assignments. The activity
then suggests nurses go on to discuss patient details and produce appropriate
priorities and plans of care. The findings from my study lend support to initiatives
94
like this one that are aimed at promoting communication and collaborative
practice among all nurses.
The second initiative is the development of the Interprofessional Network of
BC (in-BC) (in-BC, 2007). The in-BC initiative is a joint effort, developed by
members of the University of Victoria, School of Nursing in conjunction with
several educational institutions and health care agencies in BC. The goal of this
network is to create sustainable partnerships between educational institutions
and various health care agencies (e.g. BC Cancer Agency, BC Children's
Hospital, and Vancouver Acute) by promoting collaborative practice models and
programs among health care providers form numerous disciplines (e.g. medicine,
nursing, social work, rehabilitation sciences and pharmacy). The premise behind
the initiative is that health care overall will improve when members of the health
care team have a greater understanding of one another's roles and are able to
communicate and collaborate effectively. In their publication describing their
interprofessional education project, several strategies are put forward to help
them meet their goal. For example, overlapping student practicums to facilitate
collaborative practice among disciplines and case based learning activities.
These strategies could readily be applied more specifically to the education of
student RNs and LPNs to foster collaborative relationships and would have an
additional benefit of preparing them to develop collaborative relationships with
other health care team members. For example, RN and LPN student groups
already often share clinical placements but structure their times so that one
group is off the unit prior to the other group's arrival. On occasion I have been
able to encourage verbal reports between my LPN students and RN students.
However, these occurrences have been rare and sporadic. Perhaps a more
formalized approach to promoting communication between RN and LPN student
groups where possible (e.g. verbal shift reports at shift change) could be one
strategy to foster communication and collaborative practice among these nurse
groups.
Implications for Nursing Research
The findings of this research study suggest additional avenues of inquiry on
the topic of full scope LPN practice in acute care. In this section I suggest
2 possible directions for future research that would yield further information
regarding full scope LPN practice in acute care. First, I suggest a larger scale
study that could further explore the experiences and perceptions of nurses
working in a RN/LPN skill mix. In the VIHA project evaluation I mentioned earlier
in this section, the researchers utilized focus groups comprised of senior RNs
and full scope LPNs to assess the impact and experience of the implementation
of full scope LPN practice in acute and rehab settings. Perhaps a similar study,
engaging groups of practicing nurses (senior and recent graduates) and/or
groups of student nurses could help further an understanding of nurses'
knowledge of each others scopes of practice and practice experiences working in
RN/LPN skill mixes.
Several challenges to positive experiences of RN/LPN sill mix were identified
in this study. In addition to these challenges, some respondents noted that after
working together for awhile they felt more positive about working in an RN/LPN
96
skill mix. Building on the idea then that experience working together over time
contributes to positive perceptions of the RN/LPN skill mix, a longitudinal study
that involved revisiting participants after 6 months or one year following initial
contact could yield more information about the evolution of RN/LPN working
relationships over time and offer more detail about what forms the basis for a
positive change in the experience of working in an RN/LPN skill mix in acute
care.
Summary
LPNs represent a growing and valuable nursing resource in BC. Since the
introduction of full scope LPN practice in 2000 that includes an expanded range
of entry level competencies, LPNs are working in more settings with an increase
in the level of autonomy in their practice. The RNs who were used to working
with LPNs in more of a support and assistant role and RNs who are new to the
RN/LPN skill mix are challenged to view the full scope LPN in the capacity of
colleague with considerable overlap in scopes of practice, but also with distinct
limitations. LPNs who are now working to full scope are working to establish
themselves as active team members in their new role in some acute care
settings. The findings of this qualitative study offer some insight into how RNs
and LPNs perceive and experience full scope LPN practice in the acute care
setting. I suggest the findings presented here contribute to our understanding of
how RNs and LPNs are negotiating the new direction in nursing skill mix and how
they can be supported in this endeavour by clarifying factors that support and
factors that hinder RNs and LPNs working together effectively.
9 7
In summary, the findings of my study indicate that both RNs and LPNs
seemed to have a good understanding of what constitutes full scope LPN
practice. In the acute care setting, which is a high intensity work setting for
nurses (e.g. high patient acuity, complexity of patient issues, and overall
workload), RNs and LPNs are being challenged to collaborate in the provision of
patient care. Some LPNs seemed to be faced with the need to prove themselves
and establish themselves in their new role; "the RNs were very reluctant on
having LPNs on the floor, but as time progressed and the LPNs were able to
prove themselves the RNs (some of them) were able to accept" their presence
on the unit. The need of some LPNs prove themselves and assert their position
on the nursing team seemed to be spurred by some RNs who expressed concern
regarding the competence and critical thinking skills of the full scope LPN in the
context of the acute care setting.
Findings in this study also indicate the presence of some challenges faced by
RNs and LPNs since the implementation of full scope LPN practice in the acute
care setting. For example, some RNs and even one LPN did not feel that the full
scope LPN role was appropriate to their acute setting (e.g. patients too acute and
health needs too complex). Some RNs felt that the limitations of the LPN scope
of practice can result in an increased workload burden for them due to the loss of
care aide positions as LPN positions are increased. Teamwork was identified as
an area of challenge identified in the findings also. For example, some LPNs felt
the RNs were reluctant to collaborate with them or unsure of how to engage in
teamwork; "they are not taught to be team players in many areas". Some RNs felt
the LPNs were too focused on their own assignments and/or were perhaps not
yet comfortable in their own role to branch out and contribute to the team as a
whole.
Findings in this study indicate that overall, both RNs and LPNs report that
clear communication, LPN role clarity, experience working together over time,
and a supportive work environment contribute to positive experiences of the
RN/LPN skill mix. Feelings of burden, inconsistent teamwork, lack of respect,
concerns about patient acuity levels, and varied perceptions of the ability of LPNs
and RNs to assume responsibility for patient care present areas of challenge in
the workplace. In response to these findings, I proposed some strategies and
presented some current initiatives designed to build upon those factors I
identified that contribute to positive experiences of RN/LPN skill mix for nurses.
For example, strategies to encourage and support collaborative practice (e.g.
RN/LPN shift meetings and student RN and LPN workshops). The strategies
presented were also selected in hopes of addressing some of the areas of
challenge in the workplace for RNs and LPNs.
This is an exciting and challenging time for acute care nursing in BC. The
introduction of full scope LPN practice into the nursing skill mix in an increasing
number of acute care units presents challenges but also opportunities for RNs
and LPNs to collaborate in new and effective ways. In summary this study offers
a glimpse of the multifaceted impact of the introduction of the full scope LPN role
into the acute care setting on nurses who are practicing on the front line of the
change.
99
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tape recorded. All interviews will be transcribed by a professional transcriptionist.
Access to transcripts will be restricted to the investigator, Elizabeth McTaggart,
and project supervisor, Dr. Angela Henderson.
Risks and Benefits:
The only known risk to you or to others from participating in this project is
breach of confidentiality. Steps to ensure that confidentiality is not breached are
outlined in the next section.
Your participation will aid in furthering nursing's understanding of the
experiences of RNs and LPNs working together in the acute care setting.
Confidentiality:
Your participation in this project is confidential. Any information resulting from
the interview(s) will be kept confidential. All audio tapes and subsequent
documents will be identified by a code number and pseudonym that/which will be
selected in consultation with you at the time of your interview. Only your
pseudonym or study number will be used during the research process and/or in
any reports. Direct quotations from your interview may be used in the final
report, but only your designated pseudonym will be used as an identifier.
Audiotapes and transcripts will be kept in a locked filing cabinet and computer
records will be password secure.
p. 2 of 3
108
Appendix IV
Initial Interview Guide
"Describe your experience of first hearing about FSLPNs in acute care?... about
FSLPNs coming to your unit?"
"What is your understanding of FSLPN practice?"
"Can you tell me something about your experience working with or as a FSLPN"
"Tell me about your thoughts and feelings about the introduction of FSLPNs in
your workplace."
"Describe the effects, if any, of FSLPNs on your own practice."
"What does FSLPN practice mean to you?"
"Tell me about your experience of working in an RN/FSLPN skill mix."
"In your view, what does the future for FSLPNs in acute care look like?, and why
do you think that? OR, on what do you base your view?"
"Is there anything else you would like to tell me about?"
109
Appendix V
Demographic Data
Age: Sex: • Female • Male
Type of Nurse: • LPN • RN
Years of Nursing Practice:
Type(s) of nursing practice settings where you've worked previously
*e.g. acute care, long term care, critical care, hospice, other (please specify):
Did you receive you nursing education in BC? • Yes • No
*lfno, please specify where.
Have you previously worked in a health care setting in a capacity other than the
one you currently practice in as an RN or LPN? • Yes • No
* If yes, please specify.
Have you attended one of the joint RNABC / CLPNBC "RN/LPN" workshops?
*lfyes, please specify the date. • Yes / • No Month Year
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Appendix VI - Survey
Title: NURSES' EXPERIENCES OF FULL SCOPE LPN PRACTICE IN ACUTE CARE.
Instructions: Please answer the following questions (point form is acceptable).
Feel free to use additional paper as needed. Do not write your name on the
survey. Please submit your survey using the self-addressed, stamped envelope
provided. Thank you for your valuable contribution!
1. What is your understanding of Full Scope LPN practice?
2. Tell me about your thoughts and feelings about the introduction of full scope
LPN practice into your current workplace.
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3. What does FSLPN practice mean to you?
4. Tell me about your experience of working in an RN/full scope LPN skill mix in
your current work setting.
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